LIBRARY OF CONGRESS. 



Chap Copyright No. 



UNITED STATES OF AMERICA. 



VENEREAL DISEASES 



STURGIS 






THE 

Students' Manual 



OF 



VENEREAL DISEASES 



F. R. STURGIS, M.D. 



SOMETIME CLINICAL PROFESSOR OF VENEREAL DISEASES IN THE MEDICAL DEPARTMENT OF 

THE UNIVERSITY OF THE CITY OF NEW YORK ; FORMERLY ONE OF THE 

VISITING SURGEONS TO CHARITY HOSPITAL B I., DEPARTMENT 

OF VENEREAL; MEMBER OF THE AMERICAN ASSOCIATION 

OF GENITO-URINARY SURGEONS, ETC., ETC. 



SEVENTH EDITION 
REVISED AND IN PART REWRITTEN 



F. R. STURGIS, M.D. 

AND 

FOLLEN CABOT, M.D. 



INSTRUCTOR IN GENITO URINARY AND VENEREAL DISEASES IN THE CORNELL UNIVERSITY 
MEDICAL COLLEGE; GENITO-URINARY SURGEON TO BELLEVUE HOSPITAL, OUT- 
PATIENTS* DEPARTMENT \ VISITING DERMATOLOGIST TO THE NEW 
YORK CITY (CHARITY) HOSPITAL; LECTURER ON VENE- 
REAL AND GENITO - URINARY DISEASES IN 
THE UNIVERSITY OF VERMONT 



PHILADELPHIA 

P. BLAKISTON'S SON & CO. 

ICI2 WALNUT STREET 

igoi 



1588 

Library of Congress 

Two Copies Received 
JAN 4 1901 



No 



SECOND COPY 

Delivered to 

ORDER DIVISION 
JAN 7 19QI 



Copyright, 1901, by F. R. Sturgis. 



WM. F. FELL & CO., 

ELECTROTYPERS AND PRINTERS, 

1220-24 SANSON! STREET, 

PHILADELPHIA. 



TO THE 

MEDICAL STUDENTS OF THE UNITED STATES 

THIS REVISED MANUAL ON VENEREAL DISEASES IS INSCRIBED WITH 

THE HOPE THAT IT MAY BE OF ASSISTANCE TO THEM IN 

THE PROSECUTION OF THEIR VENEREAL STUDIES 



PREFACE TO THE SEVENTH EDITION. 



It had been a question in the mind of the author whether 
it was worth while to reprint a seventh edition of this little 
book, inasmuch as it had practically fulfilled its function, 
which was to teach the students of the medical department 
of the University of the City of New York to whom he was 
lecturing at the time the manual was published, but Dr. 
Cabot expressed his belief that if the book were rewritten 
and brought up to date it would again find favor among 
the coming generation of medical students and a renewed 
sale. 

So far as the author individually was concerned, he felt 
much indisposed to give time to the revision of the book, 
but upon Dr. Cabot's agreement that he would do part of 
the work Dr. Sturgis consented to take charge of the 
chapters on Chancroid and Syphilis ; Dr. Cabot to revise 
those on Gonorrhea. 

We trust that the book in its revised and improved 
shape will find acceptance by the medical students of the 
United States, to whom this book is "dedicated, and we 
venture to ask for this new and revised edition some portion 
of the kindly reception and favor which has been accorded 
to its predecessors. 



New York City. December, igoo. 



F. R. Sturgis. 
Follex Cabot, Jr. 



vn 



PREFACE TO THE FIRST EDITION. 



It has been said, with much truth, that books are read 
in inverse proportion to their length, and in preparing this 
manual I have steadily kept the question of length in view. 

Written for students of medicine, it has been my aim to 
make the book concise, and at the same time practical. I 
have, therefore, as far as possible, eschewed all mooted 
points in venereal medicine, and confine myself to giving a 
careful, and at the same time condensed, description of the 
commoner forms of venereal diseases which will fall to the 
lot of the average young practitioner to treat, together with 
the most appropriate remedies. 

How well I have accomplished my task remains for 
others than myself to say. I trust, however, that it will 
satisfy a want which, from my experience as a lecturer in 
this branch, I know exists, and with this hope I send the 
little manual into the world to take its chances. 

1 6, West Thirty-second Street, 
New York City. 1880. 



ix 



CONTENTS 



CHAPTER I. 

PAGE 

Simple Venereal Ulcer and Its Complications — The Chan- 
croid, 17 



CHAPTER II. 
Treatment of the Chancroid, . 31 

CHAPTER III. 
The Initial Lesion of Syphilis, 42 

CHAPTER IV. 

Syphilides of the Skin and Its Appendages, 57 

CHAPTER V. 
Syphilides of Mucous Membranes — Syphilitic Adenitis, . . 74 

CHAPTER VI. 
Syphilis of Special Organs, . „ . . 81 

CHAPTER VII. 
Syphilis of the Neryous System and of Bone, ..... . . 96 

CHAPTER VIII. 

Treatment of Syphilis, 106 

xi 



Xll CONTEXTS. 

CHAPTER IX, 

PAGE 

Hereditary Syphilis and Its Treatment, ......... 124 

CHAPTER X. 
Gonorrhea of Both Sexes, - 141 

CHAPTER XI. 
Complications which Occur in Gonorrhea, 154 

CHAPTER XII. 
Treatment of Gonorrhea and Its Complications, ...... 175 

Index, 207 



VENEREAL DISEASES, 



CHAPTER I. 

SIMPLE VENEREAL ULCER AND ITS COM- 
PLICATIONS.— THE CHANCROID. 

Before calling your special attention to the cases which 
I have brought from the wards for the purposes of illustra- 
tion, it may not be inapt to define what is meant by venereal 
diseases, and to set before you the principal groups into 
which they are divided. 

Speaking broadly, venereal diseases are those due to, and 
originating in, sexual contact, and although many forms 
of these diseases are transmitted without any sexual con- 
tact, as I shall show you further on, the name may, for 
convenience sake, stand. They are at present divided into 
three principal groups or divisions : Gonorrhea, chancroid, 
and syphilis. Each is distinct and separate one from the 
other, having nothing in common with each other, al- 
though they may all be present in the same person at 
the same time, and they are possessed of certain character- 
istics which are more or less peculiar to themselves. 

Of these three diseases only the last one, syphilis, is con- 
stitutional ; the other two, gonorrhea and chancroid, are local. 
I say this advisedly, notwithstanding the fact that within 
recent years cases have been reported in which systemic 
2 17 



I 8 VENEREAL DISEASES. 

infection appears to have been induced by, or to occur after, 
an attack of gonorrhea, owing to the absorption or trans- 
portation of the bacterium peculiar to gonorrhea, the 
diplococcus of Xeisser. For the present, however, you 
may assume it as true that gonorrhea and chancroid are 
local diseases ; syphilis is not : that infects the entire system. 

The first case I present for your consideration is one 
of chancroid in a male subject, whose history, I regret to 
say, is imperfect, no uncommon occurrence in cases coming 
into hospitals ; but from what I can glean from him and the 
record book, his sore, which you see is quite a large one, 
came on two or three days after coitus, and was at first quite 
small. Here is a point to which I wish you to attend, one 
of the most important upon which to base your diagnosis 
of a chancroid, and equally noteworthy as a differential 
mark between this lesion and the first manifestation of syph- 
ilis — what is commonly known as chancre. The sore came 
on two or three days after coitus ; in other words, but a short 
time elapsed between the infecting connection and the re- 
sulting ulcer. The effect was almost immediate. 

When we come to treat of syphilis, we shall find that 
this is no longer true ; an appreciable interval elapses 
between cause and effect : what is technically called the 
period of incubation. 

Chancroids, then, have at the most a very short period of 
incubation, sometimes none at all, and this depends much 
upon the manner in which the poison, or virus, so called, 
is deposited beneath the mucous membranes. If in coitus 
the membrane is abraded or torn, the chancroidal action 
begins at once, while, on the other hand, it is delayed if the 
discharge is deposited in a fold of mucous membrane or in 
a follicle ; but even then the delay is usually one of only 
from thirty -six to forty -eight hours. 



VENEREAL ULCER CHANCROID. 1 9 

Another circumstance in the case is worthy of remark : 
the ulcer has increased in size — at first, he says, it was quite 
small. This denotes, in chancroids, a tendency to spread 
and become larger instead of smaller, a tendency due to the 
destructive character of the poison. Let me say here a word 
or two about this virus, or poison. Until within a compara- 
tively short time it was believed to be an unknown quantity, 
and, notwithstanding what I am about to tell you now, I am 
inclined to believe that that definition still holds good. The 
present is an era in which the cause of nearly every disease is 
ascribed to some bacterium or bacillus, and venereal diseases 
have been no exception to this rule. Without going back 
to earliest times, let it suffice to say that about the year 
1889 an Italian of Naples, named Ducrey, discovered what 
he believed to be the bacillus of the chancroid. This he 
regarded as the solution of the virus of the chancroid. He, 
moreover, believed that there was only one form of bubo 
which accompanied the chancroid, to wit : the simple or 
inflammatory type, the chancroidal bubo being due, in his 
opinion, to auto-inoculation of the wound resulting from 
the opening of the bubo. This piece of information fell 
upon deaf and inattentive ears. 

In the same year that Ducrey published his conclusions 
Krefting, a Norwegian, published views similar to those of 
Ducrey, except as to the bubo ; on that point he differed 
from Ducrey. 

One peculiarity about this bacillus was that it was incap- 
able of artificial propagation : it could not be cultivated on 
any of the media which heretofore have been used for the 
propagation of any given bacterium on foreign soil. And, 
more than that, in the pus — for only the pus was taken by 
these two observers — there was such a variety of bacteria — 
streptococci, staphylococci, and other saprophites — that it 



20 VENEREAL DISEASES. 

was impossible to determine which given bacterium was the 
real cause of the trouble, and, inasmuch as it was incapable 
of artificial cultivation, it seemed to put an' end to the 
determination of this question. 

These two observers, remember, had merely taken the 
pus ; but in all of the specimens it was noted that there 
was an extraordinary looking bacillus which was short, with 
rather bulbous extremities, which was constant in all speci- 
mens, and this both Ducrey and Krefting considered as the 
bacillus of the chancroid, and it was known as the Ducrey - 
Krefting bacillus. 

Later Unna, a German of Hamburg; made sections of 
chancroidal tissues and therein found a bacillus which, how- 
ever, differed from the bacillus of Ducrey and Krefting 
in that it was made up of chains or long rods. This bacil- 
lus he considered a strcptobacillus, and he found in this the 
same inability to adtivatc it upon any of the usual bacterio- 
cultural media. It differs in some respects from the other 
bacillus, and some bacteriologists consider this of no import- 
ance, regarding the two as practically identical, while others 
decline to adopt this view. The same variety of bacteria 
was also discovered in these sections, but in lesser degree, 
and the further from the sin face of the ulcer the sections 
were made, the fewer became the number of other bacteria and 
the more constant became this one peculiar strcptobacillus. It 
was fairly supposed that this bacillus was therefore pathog- 
nomonic of the chancroid, and the opinion was still further 
confirmed by Krefting's experiments, in which, finding that 
he could not cultivate the bacillus by the usual methods, he 
used its natural soil — to wit, the human body — as the cidti- 
vating medium, and, by repeated auto-inoculations and exam- 
inations of the pus, he was later on able to eliminate from 
the purulent secretion of these chancroids of inoculation 



VENEREAL ULCER CHANCROID. 21 

every variety of bacterium except the one bacillus, the diplobacil- 
lus of Ducrey and Krefting ; and he also obtained this same 
bacillus from the pus of a virulent bubo. He believed that 
the bacilli of Ducrey and Unua arc the same, and that the 
question of difference in form is accidental and perhaps de- 
pendent upon different stages in the growth of the chan- 
croid. That is the position in which the matter stands at 
present, and I have explained this to you as succinctly 
as possible, in order to give you all the information with 
regard to the causation of this variety of disease ; al- 
though I am perfectly frank to say that I believe the 
importance of this discovery is grossly exaggerated. In- 
deed, I believe the statement which I made in my earlier 
editions still stands good : that it holds in venereal parlance 
much the same position that the letters x, y, and z do in alge- 
bra ; it is still an unknown quantity, notwithstanding the 
discovery of the bacilli of Ducrey-Krefting and Unna. 
As to its practical value, I am equally skeptical. It cer- 
tainly makes no difference in the treatment whether the 
bacillus is the cause or merely an accidental accompani- 
ment. The treatment will be the same in cither case ; and 
its only value will be the negative one as regards diagnosis. 
If you at the termination of your student's career are expert 
pathologists and microscopists, — which you are almost 
certain not to be, — you will find that the number of 
bacteria and microbes which you scrape off the surface of 
a chancroid will be so confusing that you probably would 
not recognize the bacillus of the chancroid were you to 
meet with it ; indeed, the excitement and interest which 
attended the subsequent discussions on the bacillus of the 
chancroid have very much diminished, and I do not think 
that the average practitioner cares much whether the 



22 VENEREAL DISEASES. 

bacillus is the cause of the chancroid or not. He knows 
his treatment will be the same in either case. 

I shall, therefore, continue the use of the term "virus," 
as it is one of great convenience and it would be difficult 
to find a good substitute. I shall certainly not speak of 
the bacillus as being the cause of the chancroid until it has 
been more clearly demonstrated that it is the real cause. 
In this connection let me call your attention briefly to the 
facts that nonvenereal sores have been capable of auto-inocu- 
lation within certain limits, — to wit, those of ecthyma and 
pustular acne, — and the secretion also of an initial lesion 
of syphilis, if this latter be irritated, is capable not only of 
auto-inoculation, but also of inoculation on another person 
without producing syphilis, albeit, as a rule, the secretions 
of syphilis are not auto-inocidable. 

Now, the bacillus of syphilis is entirely different from the 
bacillus of the chancroid, and, so far as I am aware, no 
bacillus has as yet been discovered to account for the 
presence of an ordinary ecthyma or pustular acne, and if 
this be correct, it would appear that there are other causes 
besides the presence of a bacillus to account for the auto- 
inoculability of chancroidal pus. I shall, therefore, in these 
chapters retain the word "virus," begging you, meantime, 
to remember that it means an indefinite something, endowed 
with properties, which produces certain results ; and that that 
indefinite something may possibly be due to the existence 
of a bacillus, but the correctness of which surmise must 
still be regarded as nonproven. 

To return to the chancroid. Two points we have 
brought out, and mark them well : First, a period of incu- 
bation, at the most very short, sometimes absent ; and, second, 
a tendency to destructive action. Let us now examine the 
sore and see what else we find. We notice one rather large 



VENEREAL ULCER CHANXROID. 23 

ulcer, of irregular shape, uneven floor, a moderately copious, 
purulent secretion (this has been somewhat modified by 
treatment), and upon putting the ulceration on the stretch 
we observe that it extends beyond the apparent edges of the 
sore. I repeat apparent edges, because this peculiarity has 
a decided bearing upon treatment. Chancroids frequently 
burrow, going along faster below than they do above, hence 
the external aspect of the sore is no necessary index of its 
real area ; the edges of the ulcer are undermined, and if in 
the treatment you decide to destroy the chancroid by caus- 
tics, convey the destructive agent beneath the edges and 
beyond the apparent limits of the sore, even into sound tissues. 

The number and shape of the ulcers are the next points 
which invite discussion. In this subject there happens to 
be only one ulcer, but such is not always the case, as witness 
this second man. Here we find three chancroids of various 
sizes. This multiplicity may be produced in one of two 
ways : either as original foci of infection or by inoculation. 

Note, therefore, that the chancroid is capable of self- 
propagation upon the person having it, and also upon others 
to whom the poison may be conveyed. 

It is eminently contagious and auto-inocidable. I shall 
call your attention again to this point when I come to 
speak of the initial lesion of syphilis (chancre). In shape 
the sore is irregular, owing partly to the seat — on the inner 
layer of the prepuce and the fossa glandis — and partly to 
the natural tendency chancroids have of spreading irregu- 
larly and sending out shoots, but there is often another 
reason : several chancroids may be seated close to one 
another and, by destroying the intervening sound tissue, 
present to view an ulceration with irregular scalloped 
edges. 

The secretion, as has been already said, is copious and 



24 VENEREAL DISEASES. 

purulent, caused by the destruction of tissue, for pus, as you 
know, is dead tissue. 

Have we explained all the noteworthy characteristics pre- 
sented by this chancroid ? By no means, for upon hand- 
ling it we are struck by the fact that though the ulcer is 
large and angry looking, the tissues upon which it is seated 
are perfectly supple and soft. And here let me give you a 
word of warning as to the use of the word soft, which has 
proved a fruitful cause of misunderstanding. Better ex- 
punge the word from your venereal vocabulary and call the 
chancroid a simple venereal idcer, as contradistinguished 
from the initial lesion of syphilis (chancre), which is termed 
the specific venereal ulcer. In the discussions which in 
former days have been had upon the nature of these two 
ulcers it was stated and generally believed that no soft sore 
— i. e., one which had no induration at the base — was ever 
followed by syphilitic manifestations. This belief is now 
proved to be erroneous, and sores devoid of indurated bases 
have been the precursors of secondary symptoms — in other 
words, the initial lesion of syphilis may be soft. The import- 
ance of this you will see later on. If this be true, the inap- 
plicability of the term to a chancroid is apparent, for a 
chancroid is never followed by general manifestations ; the 
initial lesion always is, and of this I shall speak more fully 
later on. Do not, therefore, call the chancroid the soft 
venereal ulcer, but simple venereal ulcer, if you do not wish 
to use the word chancroid. 

Now, to go back to the chancroid. We find no indu- 
ration at the base ; the tissue upon which it is seated is 
perfectly supple and yields readily to pressure, in a manner 
entirely different from what it does in this third patient, 
who is the subject of an initial lesion and beneath whose 
sore, on palpation, you can discover a gristly hard sub- 



VENEREAL ULCER CHANCROID. 2 5 

stance, the nature of which you will learn more about by 
and by. We have, then, discovered another trait of a 
chancroid, to wit: an absence of indurated base; but re- 
member this loses some of its diagnostic importance, from 
the fact that the initial lesion (chancre) sometimes presents 
the same peculiarity. 

Before passing to the next point let me sketch the 
salient features of a chancroid, such as we have dis- 
covered upon the cases examined to-day. They are 
these : 

Absence, or at most a very short period of incubation. 

Tendency to spread irregularly in size and depth. 

Tendency to undermining of the walls of the ulcer. 

Copious purulent secretion. 

Contagious and auto-inoculable character of the pus, thus 
producing multiple sores. 

Absence of induration of the base of the ulcer. 

Thus far we have studied the chancroid in its simplest 
form. We will now consider the complications most liable 
to occur with this disease. 

The first and the one most intimately associated with the 
chancroid is the bubo, or swelling of glands, usually those 
of the groin. This is due to two causes, the first being 
from sympathy (sympathetic inflammation), the second, and 
most serious, from absorption of chancroidal matter from 
the ulcer by the lymphatics. I am myself satisfied that 
this occurs, notwithstanding the fact that the statement has 
recently been advanced that the chancroidal bubo becomes 
so from auto-inoculation after opening the bubo, and not 
from the absorption of matter from the ulcer. 

The two subjects I bring before you illustrate these points 
beautifully. This first patient has, as you see, a large, in- 
dolent, brawny swelling in his right groin, and upon his 



26 VENEREAL DISEASES. 

penis he still bears a chancroid, but in the stage of repair. 
Number two also has a chancroid, seated close to and in- 
vading the frenum, but in his groin we find a different con- 
dition of things to what we did in number one. Here w r e 
find an open ulceration, presenting an uneven, grayish floor, 
everted and undermined edges, and secreting an abundant 
amount of pus, recalling to mind the characteristics of the 
chancroid already presented to you. Indeed, you would 
be right to call it a chancroid, for such it is : caused by the 
absorption of the chancroidal matter tlirougli the chain of 
lymphatics, and deposited in the nearest glands (in this case 
the inguinal), there to produce a condition of affairs similar 
to what obtains in the original ulcer. In other words, you 
have here a typical chancroidal bubo, pure and simple. 
These two, then, represent the varieties of bubo found with 
a chancroid ; the first one, a bubo from sympathy, which 
frequently does not suppurate, and if it does, furnishes laud- 
able, healthy pus ; the second one, the true chaficroidal bubo, 
due to absorption of matter from the ulcer, which invariably 
ulcerates and presents subsequently the appearance of a chan- 
croid — indeed, is a chancroid. 

There are two other points to which I wish to call your 
attention : the diffused brawniness of the surrounding tis- 
sues in both cases and the side of the body upon which the 
buboes are seated. 

The glands themselves do not seem to be the only parts 
affected ; the circumglandidar tissue is involved as well, pre- 
senting a thickened, doughy mass in which the glands can 
be indistinctly felt. Note this well, I pray, for when you 
come to handle cases of syphilis you will find a very oppo- 
site condition of things ; the glands will not be fused to- 
gether nor with adjacent tissue, but they will be distinct, 
well marked, and indurated. 



VENEREAL ULCER — CHANCROID. 2J 

The other point is this : in the second case the bubo is 
seated upon the groin opposite to the side of the penis upon 
which the chancroid is ; in number one it is upon the same 
side. The cause is the position of the ulcer. Deduce then 
the following rule : Buboes are usually seated upon the same 
side of the body as the uleer which causes them, except when 
it (the ulcer) is seated upon the frenum, when they will be fre- 
quently found upon the opposite side. The same is true when 
the chancroid in the female is seated upon the "fourchette" 
and this is due to the decussation of the lymphatics at these 
two points. 

In all the cases I have shown you the lesion has been 
seated upon the mucous membrane of the genitals. This is 
its usual seat, but it may be met with upon the skin of vari- 
ous parts of the body, such as the face, the head, the fin- 
gers, and, as I have seen in one case, in the throat. Such 
places are not common seats of the chancroid, so you may 
always suspect the nature of a sore when located on the parts 
I have just mentioned ; it is much more likely to be syph- 
ilitic ; at any rate, always bear that point in mind. 

The course of a chancroid is always destructive, and if 
not properly treated, may result in severe disfigurement and 
loss of tissue. 

This is especially the case when the chancroid is seated 
upon the frenum or in the urethra just within the meatus 
urinarius. In the former place perforation and destruction 
of the frenum are to be looked for ; and what will perhaps 
surprise you, is a greater loss of tissue than you had at first 
counted upon, for here, particularly, the burrowing tendency 
of the chancroid is shown, and long before the frenum is 
ulcerated through the sore has attained large dimen- 
sions. In the latter place (the urethra) the sore extends 
rapidly, is difficult of treatment from its comparative inac- 



28 VENEREAL DISEASES. 

cessibility, and upon cicatrization produces partial closure 
of the meatus, requiring subsequent surgical treatment. 

As I have already stated, these ulcers have a tendency 
to spread, and, from their facility of auto-inoculation, to 
multiply ; hence the treatment to be effective must be 
prompt and thorough. Under proper care the copious 
purulent secretion is diminished, the gray floor disappears, 
granidalions spring up over the surface of the sore, and the 
undermined edges fill up level with the walls of the ulcer. 
But bear this point in mind : a chancroid is dangerous up to 
the very moment of its complete cicatrization ; no matter how 
superficial or simple it may look, do not remit the thorough- 
ness of your treatment until cicatrization is complete. I have 
seen chancroids almost well relapse (without a fresh infec- 
tion) from just that want of care, the slight remaining dis- 
charge being sufficient to reinoculate the almost cicatrized 
sore. 

Pliagedena is another and perhaps the worst accident 
which can attack a chancroid, and when it becomes ser- 
piginous, — that is, when it extends in one direction while 
healing in another, — may last for a long time (several 
years) and seem well-nigh hopeless of cure. It, fortun- 
ately, is not common, in this section of the country at least, 
and occurs in those persons whose health is broken down 
from alcoholic excesses or constitutional debility, such as 
scrofula and the like. Remember that it is due to constitu- 
tional, not local, causes, and to combat it successfully you 
must take your measures accordingly. This grave acci- 
dent attacks not only the chancroid itself, but the chan- 
croidal bubo, lasts for an indefinite time, and will put you 
to your trumps to cure. 

Before passing on to the consideration of treatment there 
are other complications to which I wish to direct your 



VENEREAL ULCER — CHANCROID. 29 

attention, to wit : phimosis occurring with chancroid, and 
chancroids of the amis. You already know that the first of 
these complications occurs with syphilis and gonorrhea, as 
well as with chancroids, and it is important for you to be 
able to tell which one of these diseases lurks behind the 
constricted foreskin, not only for diagnosis, but for treat- 
ment. In cases of gonorrhea and chancroid there is a copi- 
ous purulent secretion from beneath the prepuce ; but in 
gonorrhea this matter is not auto-inoculable , while in chan- 
croid it is. With a chancroid the penis is much more pain- 
ful, edematous, and swollen, and the lymphatics on the dor- 
sum penis are more apt to be inflamed and tender than is 
the case in gonorrhea ; but the crucial test is auto-inoculation. 
If the hidden ulcer be an initial lesion, the secretion is very 
scanty, if indeed there be any ; the prepuce is hard and 
indurated, instead of being edematous and doughy, and the 
secretion is not auto-inoadable. 

Chancroids of the aims are, in the male subject, very rare 
indeed ; and where you find them, always suspect sodomy, 
and I believe you will seldom be wrong. The same is still 
more true as regards the initial lesion of syphilis (chancre) 
in both sexes. But with women, so far as the chancroid is 
concerned, it is different. With them anal and rectal chan- 
croids are not rare, and their presence does not imply Ve?tus 
prcepostera. The secretion from the chancroids of the 
female genitals naturally flows over the perineum and anus ; 
very few feminine ani but are abraded ; auto-inoculation 
occurs, and the thing is done, and a very nasty thing it is too. 
The ulcer extends in all directions, eats through and neu- 
tralizes the action of the sphincter ani, producing incontin- 
ence of the bowels ; burrows up into the rectum ; is con- 
tinually irritated by retained fecal matter ; is extremely dif- 
ficult to heal, and, when it finally does, nearly always leaves 



30 VENEREAL DISEASES. 

a stricture of the rectum behind it ; and if to that you add 
phagedena, a not infrequent complication in broken-down 
harlots, the picture is a pretty dismal one. 

Chancroids of the female genitals differ in no essential 
respect from those of the male in appearance or course. 
Their usual seat is at the vulva and introitus vagince ; they 
are next most frequent on the cervix uteri, and are very 
rarely met with in the vagina between these points. 

Buboes in women are not so common as in men, excepting 
when the chancroid is seated at the " fourchette," when 
they follow the same course of action as that already 
detailed in the early part of this chapter. 



CHAPTER II. 

TREATMENT OF THE CHANCROID. 

In the preceding chapter we went over the description of 
the chancroid and the complications which are its most fre- 
quent concomitants, reserving the question of treatment to a 
chapter by itself. This, then, will form the subject of this 
chapter, and at the outset I want to impress upon your minds 
the two cardinal points of treatment, which are, first, the 
arrest of the virulent and destructive character of the ideer ; 
second, cleanliness. 

First, then, as to the arrest of the virulent and destructive 
character of the ulcer. This is done either by the actual 
cautery or other caustics, in severe cases, and by alterative 
applications in mild ones. Of the first division of remedies 
the white iron, or the galvanocautery, takes the front rank 
as a destructive agent ; next to that comes the strong sul- 
phuric acid; third, chemically pure nitric acid ; fourth, pure 
carbolic acid ; fifth, chromic acid, and sixth, pyrogallic acid. 
A neat way of using the sulphuric acid is by the medication 
known as Ricord's carbosulphuric paste, which is made by 
taking a small quantity of finely powdered willow charcoal, 
adding, drop by drop, enough of the acid to make a paste 
of the consistence of thick cream. This is put on with a 
porcelain or glass spatula, taking care (remember the under- 
mined edges) to carry the agent into sound tissue both under- 
neath and on the surface of the edges of the chancroid. 
Nitric or carbolic acid may be used in the same way. The 
advantage of this method is that, besides destroying the 

3i 



32 VENEREAL DISEASES. 

virulent ulcer, it makes a firm dressing by the drying of the 
charcoal on evaporation of the acid, which, dropping off 
at the end of several days, reveals the chancroid almost, if 
not entirely, healed. If you prefer to use the acids in a 
fluid form, then some subsequent dressing must be used, 
and of all dressings I infinitely prefer the dry to the wet. 
One of the best preparations is iodoform finely powdered, 
either alone or in combination, thus : 

U . Pulv. iodoformi, I part 

Lycopodii, 2 parts. 

M. 

Triturate well. Apply locally. 

The lycopodium has, probably, only a mechanical action, 
but it absorbs fluid very readily, while the iodoform acts as 
a local stimulant and alterative. Another good prescrip- 
tion is : 

R . Pulv. iodoformi, 

Pulv. ac. tannic, p. se. 

M. 

Triturate and use locally. 

This is more astringent than the other. 
The following prescription is useful when the ulcer is 
flabby and indolent : 

&. Pulv. iodoformi, 5jj 

Zinci sulphat., . . gr. v 

Pulv. ac. tannic, 3J- 

M. 

Triturate. For local use. 

One serious objection to the use of iodoform in private 
practice is its strong and pungent odor. Many attempts 
have been made to overcome this, but they have all been 
futile ; for you may perfume and scent it as much as you 
will, the smell of iodoform lingers there still. But there 
are other preparations which have the advantage of iodo- 



TREATMENT OF THE CHANCROID. 33 

form without its disagreeable feature. These I shall men- 
tion in the order of their usefulness. They are orthoform, 
aristol, and iodol. These may be applied full strength 
without combining them with any other drug. 

Should you from any cause decide to use a wet in prefer- 
ence to a dry dressing, you will find the formulae which I 
give below as good as any you can use : 

R. Ac. carbol. cryst., 3 j — ij 

Aquae, 3 vii j- 

M. 

Or— 

R. Zinc, sulphat., gr. v-xx 

Aquae, £ij. 

M. 

This latter application is an excellent dressing where 
the ulcer is flabby and indolent. The strength of twenty 
grains to two ounces should only be used when the ulcer 
is unattended with inflammation ; if there be any, the 
weaker solution is better. 

Another very excellent dressing for chancroids is a weak 
solution of ?iitric acid, thus : 

R. Acidi nitrici, c. p., gj 

Aquae, 3 vn j« 

M. 

You observe that in the list I have written for your use the 
nitrate of silver does not appear. This may seem strange, 
for the lunar caustic is the one thing par excellence which 
is daubed over any suspicious looking ulcer. But I say to 
you, do not use it if you mean to use a caustic. Nitrate of 
silver is not, in the true sense of the term, a caustic ; its 
action is very superficial, inasmuch as it quickly forms with 
the albumin of the tissues an insoluble albuminate of silver, 
and it can not destroy deeply or thoroughly, as do the sul- 
3 



34 VENEREAL DISEASES. 

phuric and nitric acids. Confine its use, then, to those cases 
where you desire to stimulate indolent, slowly healing chan- 
croids ; when you wish to destroy, select some other agent. 

Extreme heat also seems to act favorably in the treatment 
of chancroids, but inasmuch as in private practice its use 
would be very inconvenient, — and, indeed, it is likely that 
patients would not carry it out efficiently or faithfully, — it 
will be of very little value, except so far as its use in hos- 
pitals is concerned. The usual way of using it is by put- 
ting the patient into a hot-water bath of a temperature of 
from ioo° to 105 ° F., and even higher, if the patient can 
stand it, for from five to fifteen minutes. Another way, 
and one which is admissible in private practice, is to soak 
the penis in hot water to the point of faintness ; and a third 
way is by the application of bags full of hot sand, surround- 
ing the penis with them. This last I think is very uncer- 
tain in its use and of small value. 

The foregoing rules for treatment are good where the le- 
sion is exposed and accessible, but how shall we act in cases 
where chancroids are concealed either in the urethra or behind 
a phimosis ? The first object to be attained is to relieve the 
phimosis ; the second, to check the extension of the chan- 
croid. In the first place you will find nothing better than 
freely bathing the genitals in hot water (as hot as the patient 
can bear it, even to the point of faintness) several times daily, 
and at night wrapping the penis up in a bandage wet with 
the following lotion : 

R. Liquor, plumb, subacetat., 

Tinct. opii, aa ^j 

Aquse, ad ^ viij. 

M. 

SiG. — Locally. 

In conjunction with the hot bathing subpreputial injec- 



TREATMENT OF THE CHANCROID. 35 

tions should be made several times during the day with a 
solution of carbolic or nitric acid, in the following manner : 
with a flat-billed syringe made of hard rubber throw up hot 
water between the prepuce and glans penis until the return 
flow shows no shreds or fibers ; then, with the same instru- 
ment, inject carefully two syringefuls of either of the follow- 
ing solutions : 

&. Ac. carbol. cryst., 3 ss ~j 

Aquae, ^ viij. 

M. 

Or— 

$. Ac. nitric, c. p., ^ss 

Aquae, ^virj. 

M. 

Care should be taken to see that the fluid reaches well back 
to all portions of the fossa glandis. After this is done a small 
dossil of lint or prepared cotton should be lightly placed at the 
orifice of the prepuce, between it and the glans penis. This 
plan of procedure should be steadily persevered in until the 
prepuce can be retracted and the glans penis freely exposed, 
when the chancroids can be treated as already advised. 

Suppose this happy result is not attainable, what then must 
we look for ? It may happen that the swelling and inflam- 
mation, instead of subsiding, increase ; the entire organ 
becomes enormously edematous and purple, threatening 
gangrene, and it is evident that a very serious condition of 
things obtains; in fact, gangre?ie will rapidly supervene unless 
active measures are adopted to check it. 

Sometimes, happily very rarely, the sphacelus attacks a 
large portion of the penis, causing very serious conse- 
quences ; but usually it is confined to narrower limits, and 
nature is satisfied when she has relieved the constriction and 
reestablished the circulation. This she does in the follow- 
ing manner : One or more spots of a purple hue appear 



$6 VENEREAL DISEASES. 

upon the swollen prepuce, at points corresponding with the 
imprisoned glans penis beneath ; these spots get darker in 
color, extend and coalesce, and by becoming gradually 
thinner admit of the exit of the glans penis through the 
opening safe and sound. The redundant and useless fore- 
skin may be subsequently removed by operation. This is 
the course where everything goes on smoothly and safely, 
but sometimes active surgical interference becomes requi- 
site. This happens when it is evident that extensive loss 
of tissue must supervene before the imprisoned glans penis 
can be liberated, and here you have to choose carefully be- 
tween two evils. You must overcome the constriction by 
cutting through it ; but remember what I have already told 
you about the contagions character of the chancroid. The 
cut edges of the incision are sure to become inoculated, hence I 
advise you not to operate unless you must do so to save your 
patient from something worse than an extension of the chan- 
croid. But if you must cut, let me give you one or two hints 
as to the method. Carry your director between the prepuce 
and the glans penis in the median line * (be careful not to pass 
it into the urethra), and then slit the foreskin well up to the 
fossa glandis ; that will liberate the glans, and, on retract- 
ing the prepuce, search for the chancroids. Destroy them 
at once with one of the strong caustics already mentioned, 
and at the same time cauterize the cut edges of the wound you 
have made. The subsequent dressing will be similar to 
the one I have already advised. The " dog's-ears " left by 
the operation may be subsequently removed by circumci- 
sion, but not until the chancroids have entirely healed. 

If the chancroid be in the urethra, your tactics must vary 



* The incisions are sometimes made upon the two sides instead of in the 
median line. This variety of incision is better if the foreskin is veiy much 
thickened. 



TREATMENT OF THE CHANCROID. 37 

a little. When situated close to the meatus, separation of 
the lips will expose the sore, which may be cauterized and 
dressed with one of the wet preparations previously men- 
tioned. When beyond reach, upon separation of the lips 
of the meatus you must use a weak injection of carbolized * 
or otherwise medicated fluid, and afterward insert a dossil 
of lint or cotton wet with the same solution within the 
urethra. 

Contraction of the meatus left upon cicatrization of the 
chancroid may be remedied by slitting the meatus with a 
bistoury or a meatotome. 

Such dressings — indeed all dressings for the treatment of 
chancroids — should be applied three or four times daily, at 
the least. 

When the chancroid is seated at the frenum, threatening 
perforation, do not wait for the ulcer to eat its way through, 
but anticipate matters by cutting the frenum. If hemor- 
rhage result from the small artery seated in the frenum, 
tie, if requisite, but torsion will check bleeding in the 
majority of cases. You must then treat the chancroid, 
which will often turn out much larger than you at first sup- 
posed, by the rules I have already given you. 

As regards the treatment of buboes, the rules are simple 
and easily laid down. Until the bubo breaks you can not 
be certain whether it is a simple or a chancroidal one you 
have to deal with. Your first efforts, therefore, should be 
to cause absorption ; if the bubo is n on virulent, you are 
often successful ; but if, on the other hand, the bubo is due 
to the absorption of matter from the chancroid, you will 
find the swelling extend, the bubo rapidly become softer, 
and fluctuation more pronounced. The moment you are sure 



38 VENEREAL DISEASES. 

of fluctuation open the bubo, and this for a twofold reason. 
Pus, in my experience, whether due to virulent or nonviru- 
lent buboes, is not absorbed when once it begins to form, 
and under these circumstances it is much better evacuated. 
If the bubo be a simple one, the moment the pus is let out 
the bubo heals up ; if, on the other hand, it be virulent, the 
sooner you know this the better for your patient. But we 
will suppose that the bubo has not as yet shown any fluctu- 
ation ; what methods shall we adopt to prevent the forma- 
tion of pus ? Four — viz., leeclies, rest, compression, and the 
local application of the tincture of iodin. This latter must 
be applied at least once every day up to the point of vesica- 
tion, and as soon as this is accomplished you will find the 
employment of the lead plaster of service. Compres- 
sion, if you can persuade your patient to go to bed, can be 
best obtained by placing a bag of small shot, weighing from 
two to four pounds, or a brick w r rapped in flannel, directly 
upon the swelling ; if your patient will not keep on his back, 
use a layer of compressed sponge and a spica bandage, 
which wet as soon as applied, when you will get even 
and firm compression from the swelling of the sponge. 
Should your attempts at resolution fail and suppuration 
threaten, favor it, as far as possible, by the application of 
poultices. 

A word or two with regard to the application of leeches, 
should you deem them requisite. Always place them at 
some distance from, and never on, the bubo. Do not for- 
get this, else you will run the risk of inoculating sound 
tissue from the leech-bites, if the bubo should prove to be 
chancroidal. It is seldom that leeches are of much ser- 
vice, and I should advise you to be chary of their use ; 
they are not superior to the other methods I have men- 
tioned. 



TREATMENT OF THE CHANCROID. 39 

The bubo is now ripe and is ready for the knife ; how is 
it to be opened ? I prefer doing so by an incision parallel 
with the long axis of the body first, and then, if requisite, 
carry the cut upward and downward in the direction of 
Poupart's ligament. Lay sinuses open wherever you find 
than if you hope to make a speedy and permanent cure. 
After the bubo is thoroughly opened, stanch the bleeding 
(exposure to the air will suffice in most cases ; if not, use 
ice-cold compresses), and in cases of simple buboes dress 
the wound with a weak carbolized lotion applied on cotton 
or lint. If, however, the bubo be chancroidal, cauterize it 
first according to the directions already laid down for cau- 
terizing chancroids, and make what subsequent dressings 
you deem advisable, carefully packing the material well 
beneath the undermined edges. 

An honest, free incision is, I believe, nine times in ten 
the best and quickest way to treat these lesions, but I will 
mention two other methods in vogue. One is by aspira- 
tion — i. e., exhausting the bubo of its contents by suc- 
tion with Dieulafoy's aspirator or the American modifi- 
cations of his instrument. The other is by breaking up the 
bubo — i. e., churning its contents with a blunt-pointed bis- 
toury — a small incision having first been made to admit 
the entrance of the bistoury. Both of these methods are, 
of course, only applicable to the nonvindent bubo, and even 
here I think other means are preferable. 

If internal treatment be thought worthy of trial, it must 
be borne in mind that it is for its tonic effect more than 
anything else. Treatment directed toward checking sup- 
puration I have found of very little value, although in the 
early editions of this work I spoke of calcium sulphid as a 
remedy which might produce this effect. Subsequent trials 
of this drug have forced me to the conclusion that it is 



40 VENEREAL DISEASES. 

practically inert. The tonics most in use are dried ferrous 
sulphate, one to three grains, or reduced iron, one to two 
grains, in pill form, three times daily ; the sulphate of 
quinin or dextroquinin, two to three grains, three times 
daily ; and cod-liver oil, one drachm to one-half ounce, in 
similar doses. Of course, you will not forget nutritious 
diet and stimulants, as they are needed, but I should advise 
you to use the latter as little as possible. Venereal patients 
do better, as a ride, without alcohol. 

There is one other subject in connection with these dis- 
eases which I wish to discuss with you before bringing this 
chapter to a close, and that is the one of phagedena. It 
will be sufficient to recall to your minds the cases of the three 
women which I showed you a short time since, where the 
ulceration had crept over the nates and down the thighs, up 
the abdomen and along the groins, breaking down the 
rectovaginal wall and destroying the labia vulvae, to im- 
press upon you the necessity of a vigorous treatment. Re- 
member what I have already said to you about phagedena, 
that it is due to constitutional, not local, causes, and this will 
be the keynote of your treatment, although not to the ex- 
clusion of local remedies ; your main reliance must be upon 
internal and constitutional measures. Foremost in this latter 
class stands the potassiotartrate of iron, which Ricord 
called the " born enemy of phagedena," and which he was 
in the habit of applying both topically and by the mouth, 
thus : 

R. Ferri et potas. tart., %) 

Aqua, ]|vj. 

M. 

SlG. — Internally, in teaspoonful doses, thrice daily ; also for local 
application as occasion requires. 

A strongly carbolized lotion will oftentimes be of service 
as a dressing in phagedenic chancroids, viz. : 



TREATMENT OF THE CHANCROID. 4 1 

R. Ac. carbol. cryst., 3'j- v 

Aqure, Oj. 

M. 

SlG. — Locally. 

By far the most frequent cause of phagedena is that con- 
dition of the system known as " chronic alcoholism" and 
which it should be your aim to relieve as far as possible. In 
.such cases you will find the following prescription a ser- 
viceable one : 

R. 01. morrh., ^ss 

Ac. phosph. dil., Tt\x-xxx. 

M. 

In one dose. 

SlG. — Three times daily, or oftener if necessary. 

This seems to act by toning up the depressed nervous 
system of chronic drunkards, and giving the body a chance 
to combat the disease. 

Other tonics which are suitable in such cases are those 
which I have previously mentioned. 

Among the local dressings, the potassiotartrate of iron 
and the carbolic acid are the best, but I wish to say a few 
words about the extirpation of a phagedenic chancroid. The 
only agents which are of any real value for that purpose 
are the hot iron and the galvanocautery ; the corrosive 
acids I have previously mentioned are of little use. In 
applying either of these agents remember to have the heat 
white, not red, for two reasons : first, because it is more 
effective ; second, because it is less painful. Remember 
also to carry the destruction of tissue, as in the case of the 
acids, beyond the diseased parts. 

These constitute the most practical points in the treat- 
ment of this important affection ; and I have, as far as pos- 
sible, confined mvself to giving vou what I have found the 

J O O J 

most efficacious remedies, without cumbering your minds 
with numbers of useless prescriptions. 
4 



CHAPTER III. 

THE INITIAL LESION OF SYPHILIS. 

In this chapter we break ground upon one of the most 
important venereal diseases which can afflict mankind, im- 
portant not only from its effects upon the original bearer of 
the disease, but also from the horrible consequences which 
may be entailed upon the offspring of the syphilitic person ; 
and in dealing with syphilis I shall try to give you, as 
clearly and practically as I can, the chief points of the dis- 
ease, and in what its first symptom, the initial lesion, differs 
from the chancroid. 

In the first place, let me explain why I abandon the 
name chancre. First, because it is confusing ; and second, 
because it means notliing. The French, English, and most 
American writers call the syphilitic sore chancre, and the 
local venereal sore the chancroid ; but the Germans ex- 
punge the word chancroid from their vocabulary, calling 
that lesion chancre, and our chancre the initial lesion 
of syphilis ; this multiplication of names is confusing. 
Chancre, originally derived from cancer, means " something 
which eats or destroys." Now, the initial lesion does not 
destroy, and the word chancre does not necessarily mean 
anything syphilitic ; but to say initial lesion of syphilis, 
means that it is the first symptom of acquired syphilis. 

And bear this well in mind, it is syphilis already ; no 
local lesion, as is the chancroid, but the first symptom of a 
disease which is always serious, sometimes grave in its re- 
sults, and connected with other symptoms which do not 

42 



THE INITIAL LESION OF SYPHILIS. 43 

appear until some weeks after. I shall therefore call the 
first symptom of syphilis the initial lesion, and entirely aban- 
don the word chancre. 

The first case I have to present is of interest in several 
ways ; and before commenting at length upon it, let me 
give you a kxv points in the history : The patient, a stout, 
well-built young fellow, twenty-four years of age, was ad- 
mitted to the hospital November 7th. He says he has had 
gonorrhea and chancroid- several times, but you observe 
syphilis is not included in the category. A very noteworthy 
omission. Very rarely indeed does a patient contract syphi'is 
more than once in a lifetime ; chancroid and gonorrhea can 
be caught ad libitum. But to go on with the history : On 
August 9th of the current year he contracted his present 
sore, thirteen days, he declares, after the connection. Here 
let us pause : thirteen days after coitus the sore breaks out. 
You remember what we found to be the case in studying 
the chancroid, " the sore came on two or three days after 
coitus " ; here it is thirteen — four to six times longer. De- 
duce, then, this axiom : The initial lesion of syphilis is en- 
dowed with a period of incubatioji which is denied to the 
chancroid ; but there is something still more interesting in 
this thirteen days' incubation. As a rule, the incubative 
stage of the initial lesion is longer : it usually lasts from 
twenty-one to twenty '-eight days after the infecting connection. 
If, then, we reckon twenty-four days as the average period 
of incubation, thirteen days, the incubative period in this case, 
are shorter than usual, although it is not the shortest time 
recorded. The limits which are now recognized are, maxi- 
mum, ninety-eight days, minimum, ten ; and although these 
represent extreme cases, bear the possibility of their occur- 
rence in mind in making your diagnosis. Those instances in 
which the period of incubation exceeds the maximum which 



44 VENEREAL DISEASES. 

I have given you may discard, as they are based either 
upon errors in calculation or upon mistakes in diagnosis, 
and you may, therefore, adopt the following formula : 
Always suspect the nature of a venereal sore which has not 
appeared until ten days or more after coitus. 

The history goes on to say that " it (the sore) com- 
menced on the under surface and on the right side of 
the prepuce, and the soreness, swelling, and induration came 
on within four days. At present he has an induration ex- 
tending all over his prepuce." 

The induration, which is very perceptible, is, under the 
finger, of a hard, resilient character, entirely distinct and 
separated from the surrounding tissues, and is seated upon a 
noninflammatory base. Contrast this with what we found 
in the chancroid. In the latter the tissues were soft and 
supple ; there was no induration, and the ulcer was angry 
looking — inflamed, in other words. In the initial lesion un- 
der observation the ulcer, if indeed we can call it an ulcer, 
is very superficial ; it resembles an erosion ; the floor 
is clean and red in hue, the edges sloping and not under- 
nnncd. 

Another point of interest is the fact that this variety of 
venereal ulcer does not have any tendency to spread nor to 
eat into the tissues, as does the chancroid ; indeed, its whole 
course is cold and slow, and shows, nine times in ten, a 
greater inclination to Ileal than to extend — another point 
of difference between it and the chancroid, in which we 
found the opposite attributes. 

Besides this, we observe the singleness of the lesion and the 
scantiness of the secretion as noteworthy conditions of differ- 
ence between the two varieties of ulcer. With regard to 
the singleness of the lesion, you remember we found in 
chancroids that multiplicity was not exceptional, and that 



THE INITIAL LESION OF SYPHILIS. 4$ 

this was brought about in two ways : either as independent 
foci of infection or by auto-inoculation : but in the initial 
lesion of syphilis multiple sores are the exception rather than 
the rule, and when they occur, it is as independent foci of 
infection, never from auto-inoculation. Bear in mind, then, 
that the secretions of syphilis can not be inocidatcd as syphilis 
upon a syphilitic person. 

Now, while it is true that the secretions of syphilis are 
not inoculable as syphilis upon a syphilitic person, yet the 
secretion of an initial lesion or of a mucous patch, if irri- 
tated into purulent secretion, is capable not only of auto- 
inoculation upon the bearer of the sore, but it is also capa- 
ble of being inoculated upon a nonsyphilitic subject without 
producing syphilis, acting somewhat as the chancroid does, 
but with this important exception — that the ulcerations 
produced by this artificial inocidation do not have a tendency 
to spread to or destroy tissue ; on the contrary, they usually 
show a tendency to get well unless they are further irritated. 

The nature of the secretion is also deserving of a few- 
words : it is thin and scanty, not abundant and pundeut, as 
we find it in chancroids, and unless the ulcer is irritated 
from some cause, never becomes purulent. 

I wish now to call your attention particularly to the in- 
duration, for this is a very important point, and one upon 
which too much stress can not be laid. Whenever this 
symptom is found clearly and well marked, it is of value as 
stamping the lesion with a character. But there are many 
cases in which the induration is very thin and slight (parch- 
ment induration) ; nay, more, where the induration is en- 
tirely wanting. Yet the sore has not changed its nature ; it 
is still syphilis, and will be followed by secondary symptoms 
as certainly as is the hard variety. This is why I urged 
you, when speaking of the chancroid, to abandon the use of 



46 VENEREAL DISEASES. 

the word " soft " ; for if you regard the soft sore as the one 
which is par excellence local and does not infect the consti- 
tution, what are you going to say of the sore which does 
contaminate, or, to speak more strictly, which is the first 
symptom of systemic contamination, yet which is " soft " ? 
Pray what does the name tell you ? Nothing ; but chan- 
croid and initial lesion do mean something ; they tell you 
that the first is a local disease ; the second, a constitutional 
one. 

The term " hard sore " is also objectionable, because the 
hard sore means syphilis, in contradistinction to the " soft 
sore," which means the opposite ; and yet some soft sores 
are syphilis. No ! I think the names I give you are the 
best ; if you know better ones adopt them ; if not, use these 
with me. 

Let me then give you another formula : 

The initial lesion of syphilis is usually indurated ; when 
present, this symptom is of great value ; but its absence, 
which sometimes happens, does not change the nature of the 
lesion ; it still remains syphilis. When the induration is 
absent, the diagnosis must be made from other characteristics. 

We will now pass on to study the condition of the glands 
in the commencing stage of syphilis, and here we shall find 
many points of difference between the initial lesion and the 
chancroid. 

To go back a little : you remember in studying the 
chancroid we found that the inguinal glands 'were thickened 
and brawny — confounded, so to speak, with the surround- 
ing tissues in such a manner as to make a doughy mass, 
which showed, moreover, decided inflammation. Turn to 
the cases before us, and what do we find ? The glands in 
the groin are enlarged ^ it is true, but they are perfectly dis- 
tinct from one another ; they roll about under the skin 



THE INITIAL LESION OF SYPHILIS. 47 

freely and easily. When handled, they are not fused together 
nor with circumjacent tissue, as is the case with the chan- 
croid, and they are painless. 

Could anything be more opposite than these two kinds of 
bubo ? yet this is not all. Syphilitic buboes rarely suppu- 
rate ; when they do, it is from some other cause than the 
Syphilis — generally from debility or an enfeebled constitution, 
and the pus they furnish is laudable and incapable of convey- 
ing the disease either to the bearer of the lesion or to others ; 
in other words, they are simple abscesses, such as you are 
liable to meet with in any person who is run down in 
health. Neither are they dependent upon the site of the 
initial lesion, but are met with on both sides of the body and 
are not due to the systemic poisoning which has occurred ; 
they are due to some other cause than the one which has pro- 
duced the initial lesion ; nor are they due to absorptio?i of mat- 
ter from the ulcer. 

When I come to speak of the subsequent syphilitic symp- 
toms, I shall show you how the glands over the body are 
similarly enlarged — what is called the adenitis universalis 
syphilitica. 

Of the initial lesion of syphilis there are several varieties : 
the archetype, sometimes called the Hunterian induration, 
you have already seen. You can tell it as far as you can 
see it, and it is unmistakable, but unfortunately it is not 
always present. Sometimes the initial lesion has but a thin, 
disc -like layer of induration beneath it, which gives to the 
finger the sensation of a slight layer of parchment beneath 
the skin or mucous membrane — the "parchment induration " 
which I have already brought to your notice ; and, again, 
very rarely, it is true, there may be no induration at all. The 
ulceration in the initial lesion is usually very superficial, and 
when seated upon a markedly indurated base, is raised 



48 VENEREAL DISEASES. 

above the surrounding tissue ; it is then known as the 
ulcus elevatum, and again it may be a mere erosion which, 
conjoined with little or no induration, is very puzzling and 
apt to mislead the surgeon as to its true character. Beware 
of such! Do not be in a hurry to pronounce positively on 
the nature of any such lesion, but suspend judgment, else 
you may make an awkward mistake by calling a given 
lesion innocent which a few weeks later will be followed 
by a general outbreak upon the skin and mucous mem- 
branes. In addition, the initial lesion has no destructive 
tendency, no undermined edges, no gray floor ; on the 
contrary, it has a red granulating appearance, with often- 
times a dark spot in the centre, and is prone to bleed readily 
upon handling. 

In those cases where the initial lesion itself gives little or 
no information appeal to the chain of glands nearest to the 
lesion. You will seldom find them intact, and their indura- 
tion will often help you to a diagnosis. 

Let me, before going further, make in tabular form a 
comparison between the initial lesion and the chancroid : 

Chancroid. Initial Lesion. 

Little if any period of incubation. Decided period of incubation. 

Destructive, with tendency to spread. Not destructive ; tends to heal rap- 
idly. 

Edges undermined. Edges sloping, not undermined. 

Copious, purulent secretion. Scanty, serous secretion. 

Contagious and auto-inoculable char- Secretion not auto-inoculable. 
acter of the pus. 

Usually multiple. Usually single. 

Not seated upon an indurated base. Generally indurated ; sometimes — 

rarely, however — not. 

Glands liable to become inflamed ; Glands indurated, not inflamed ; very 
when so, they may suppurate and rarely suppurate, and then from 

become a chancroid, furnishing causes other than syphilis. Never 

inoculable pus. furnish inoculable pus. 



THE INITIAL LESION OF SYPHILIS. 49 

This gives you, at a glance, the important points of dif- 
ference between the two ulcers. 

The site of the initial lesion is a point of much interest, 
and I wish to recall to your minds what I said in an earlier 
chapter about some forms of venereal diseases being trans- 
mitted without sexual contact. This is the case in syphilis, 
the initial lesion not infrequently being met with upon the 
lips, the cheek, or upon the nipple ; in the first two cases 
from kissing or from using contaminated utensils, a pipe, a 
spoon, or drinking-vessels ; and in the latter, from suckling 
a syphilitic child. Other places are the fingers, the nose, 
the tongue, the throat, and the palpebral conjunctiva of the 
eye ; in short, lay it down as an axiom that no portion of the 
body is exempt from being the seat of the initial lesion, 
although the genitals are the usual location, and naturally so 
from being more exposed. 

The source of infection is another point to which I invite 
your attention. A chancroid, as I have already explained 
to you, comes either from a chancroid or a chancroidal bubo , 
but syphilis is caused in other ways than from inoculation 
of the secretion of a?i initial lesion. The secretion from 
mucous patches, whether of skin or mucous membranes, as 
well as the blood of the syphilitic during the first twelve 
months at least of the disease, are capable of infecting a 
sound person, but, as I have already told you, they are not 
auto-inoculable , except in unusual instances. The physio- 
logical secretions, such as the tears, saliva, sweat, milk, and 
semen, are all innocuous so far as the question of direct 
inoculation is concerned. This latter, the semen, however, 
may possibly be an exception, for although it is perfectly true 
that attempts at direct inocidation made from human semen 
have been negative, it is believed by some to be capable of 
contaminating the human ovum, producing syphilis in the off- 



50 VENEREAL DISEASES. 

spring without the mother participating in the syphilis of the 
father. It is the contagious property of blood and mucous 
patches which causes many of the initial lesions of the lips, 
cheeks, and nipple ; the patient, not being aware of the 
danger, kisses healthy persons, who, perhaps, have an 
abrasion of the lips, and the disease is conveyed to them. 
As regards the nipples, the mucous patches of the baby's 
mouth perform the same office for the nurse, 

Suppose the infection is derived in one case from the 
secretion of an initial lesion, in the second from that of a 
mucous patch, and in the third from syphilitic blood, 
how does the disease begin in these cases ? Always by 
an iidtial lesion seated at the point where the virus gained 
entrance ; never in any other way. The only exception to 
the initial lesion being the first symptom of syphilis is 
found in the hereditary form, where the disease shows its 
appearance without any initial lesion having preceded the 
outbreak. Syphilis does not make its appearance in the form 
of a so-called secondary eruption without a preceding initial 
lesion, although there are some cases where this would seem 
to be so. These cases are when the initial lesion is seated 
in some unusual or not readily accessible place — as, for ex- 
ample, in the urethra of the male, in the cervix uteri, upon 
the lips ox fingers of both sexes. When it is seated in the 
urethra, palpation often reveals the remaining induration, 
and sometimes separation of the labia urethral reveals the 
syphilitic erosion ; a slight, gleet-like discharge is also 
present. 

Another cause of confusion, when the patient has not come 
under observation until after the outbreak of general symp- 
toms, is that the initial lesion becomes changed into a mucous 
patch — a symptom of the so-called secondary stage ; but 
even here the traces of the induration will put you upon 



THE INITIAL LESION OF SYPHILIS. 5 I 

your guard as to the real nature of this supposed mucous 
patch. 

The initial lesion is also subject to complications, though 
to a less extent than the chancroid, the principal ones being 
phimosis and phagedena. When phimosis attacks the ini- 
tial lesion, it is not so likely to produce such serious con- 
sequences as when it occurs with the chancroid, owing to 
the inflammation being much less, and also to the fact 
that the initial lesion does not ulcerate. The only danger 
to be apprehended from this complication is gangrene, and 
that may be so readily and easily obviated by an incision as 
practically to rob it of one-half its danger. You note that 
I said " easily obviated by an incision," and I wish you here 
to remember what was said in regard to this complication 
when speaking of the chancroid. Then I advised you not 
to cut unless obliged to, because the edges of the wound 
would become chancroidal ; but in the initial lesion no such 
danger is to be apprehended ; the secretion of the lesion and 
the blood of the. syphilitic are incapable of being auto-inocu- 
lated. You may, therefore, operate, if you see fit, at once, 
so far as contagion is concerned, but I should advise zvaiting 
a little while, for the following reasons : first, because no 
operation should be done if the same result can be attained in 
any other way ; and, secondly, because the induration, even 
if very thick and marked, will disappear under proper treat- 
ment, and, with it, the phimosis. But should gangrene 
threaten, then you not only may, but should, operate to avert 
this threatened evil, and you may practise the single or the 
double incision already advised in chapter n. 

Phagedena in syphilis is of as grave import as in chan- 
croid, and comes from the same cause, viz. : constitutional 
defects, due to alcoholic abuse or to a morbid diathesis, and 
it plays an important part as regards prognosis. The 



52 VENEREAL DISEASES. 

ulceration, instead of being superficial, then becomes deep 
and wide-spread, the floor is gray and pultaceous, the secre- 
tion more abundant, and the induration may entirely melt 
away under the phagedenic action. Where the initial lesion 
is phagedenic, the subseqicent lesions are apt to take on ulcer- 
ation and to pursue a rapid course, being rebellious to treat- 
ment and exposing the patient to grave and serious conse- 
quences. 

When we were discussing the chancroid, you remember 
I took occasion to speak to you about the virus of that dis- 
ease, and I told you that while it was a term of convenience, 
the disease might possibly be due to the existence of a bacil- 
lus, and in these days when everything in heaven above 
and in the earth beneath is considered to be due to the 
presence of some bacterium it would be singular if syphilis 
escaped ; nor does it. The so-called bacillus of syphilis 
has been named after its discoverer, Lustgarten, who states 
that it is never found free in the tissues, but is inclosed only 
in the cells. It is not easy to find, and by some syphilog- 
raphers it is doubted as being the cause of syphilis. Now, 
while it is possible that this bacillus of Lustgarten may be 
the real cause of syphilis, the present condition of our 
knowledge causes us to give the Scotch verdict of " not 
proven" ; hence I repeat here what I said when speak- 
ing of the bacillus of the chancroid, that I shall retain 
the words "syphilitic virus," and you must understand 
that this is an unknown quantity which is endowed with 
certain properties and which produces certain results. 
These may possibly be due to the existence of a microbe, but 
its presence is not sufficiently established to say positively that 
it is the cause of the syphilis. 

Before going on to speak of treatment, let me say a few 
words about what is generally called the " mixed sore." I 



THE INITIAL LESION OF SYPHILIS. 53 

wish the term could be abandoned, as it is confusing and 
does not convey a correct idea of the facts. It is really a 
double sore : there is no mixture whatever of nature, course, 
or virus ; it is simply where inoculation of a chancroid and 
syphilis occur simultaneously in the same person. The two 
poisons being received at the same coitus, they operate dif- 
ferently as regards the time of their appearance. The chan- 
croid appears first ; remember, it has no period of incuba- 
tion, and runs its course and perhaps gets well before the 
initial lesion comes upon the stage. At a later period, 
usually varying from ten to twenty-one days after the in- 
fecting coitus, the initial lesion appears, marked by its pecu- 
liar characteristics. It sometimes happens that the chan- 
croid has not healed before the first symptom of syphilis is 
due. This, then, is what happens : the chancroid is sur- 
rounded with a ring of induration, the secretion becomes 
less copious, the floor fills up and appears redder and 
healthier, and the nearest chain of glands is indurated; the 
chancroid, in other words, has become changed into an ini- 
tial lesion. But throughout the whole performance there is 
no interchange of characteristics, the two lesions remain entirely 
distinct, and " mixed chancre " is, to my mind, a misnomer ; 
I prefer to call it a double infection, double in the sense 
that two kinds of virus have been deposited in the same spot. 
It is in these cases of double infection that you will be most 
likely to meet with a suppurating bubo, the pus of which is 
auto-inoadable, and which, unless you are forewarned, may 
lead you to believe that syphilis is attended by a suppurat- 
ing, auto-inoculable bubo. The bubo is chancroidal, similar 
to what we have already studied, has nothing to do with the 
syphilis, although it is contemporaneous with the initial 
lesion, and will require the treatment appropriate to chan- 
croidal buboes. 



54 VENEREAL DISEASES. 

As regards treatment, it is simple and, so far as the local 
trouble is concerned, effective in the majority of cases. In 
the first place, let me beg of you never to cauterize an initial 
lesion unless it should be attacked by phagedena. I know it 
is the rule to cauterize every suspicious looking ulcer, but 
in the case of the initial lesion this not only docs harm, by 
irritating an otherwise simple ulceration, but it retards its 
healing. Dress the lesion simply : sometimes a piece of lint 
laid over the ulceration or erosion will suffice, but at other 
times a little more active treatment may be requisite. Of 
all dressings, I much prefer the dry, and of them iodoform 
heads the list, either alone or in combination with other 
drugs, thus : 

R. Pulv. iodoformi, 

Lycopodii pulv., p. ae. 

M. 

Or— 

R. Pulv. zinc, ox., ^ij 

Pulv. iodoformi, 5JJ* 

M. 

Or— 

R. Pulv. hydrarg. chlor. mit., 3J 

Pulv. iodoformi, 3 ij. 

M. 

Calomel, without anything else, may sometimes be used 
with advantage, but you must remember that calomel often 
acts as an irritant and produces an inflammation in a lesion 
which otherwise would remain bland and uninflamed. 

As iodoform is as objectionable in syphilis as in the sim- 
ple venereal ulcer on account of its pungent odor, you may 
also use here the same local dressings that you did in the 
chancroid, to wit : orthoform, aristol, and iodol ; indeed, the 
tendency of the initial lesion is, as a rule, toward cicatriza- 
tion, unless you imprudently meddle with it ; hence you 



THE INITIAL LESION OF SYPHILIS. 55 

may formulate this axiom : In the treatment of the initial 
lesion the simplest and least irritating dressings are the best. 

Another method, known as the abortive treatment, at one 
time attracted attention, and that was the excision of the ini- 
tial lesion, wherever it was possible to remove it, upon the 
theory that if this were done soon enough, constitutional in- 
fection would not follow, the argument being that the ini- 
tial lesion was the starting-point of the disease. Subse- 
quent experience has shown that no matter how soon the 
initial lesion may be ablated, it does not prevent subsequent 
manifestations from appearing, although in some instances 
the subsequent lesions have been delayed beyond the time of 
their usual appearance. This delay does not necessarily de- 
pend upon the removal of the sclerosis, because we know 
that, occasionally, the appearance of the initial lesion may 
be somewhat delayed, and the fact that subsequent symp- 
toms did appear in spite of this slight operation would go to 
prove what I believe to be perfectly correct, that the sys- 
temic infection takes place at the time of the conlagiotis coitus ; 
in other words, the initial lesion is only the first manifesta- 
tion of a previous poison, dating back, say, twenty -four days, 
and is not the starting-point of the constitutional poisoning. 

If you prefer to use a wet dressing, a weak solution of 
carbolic acid is the best, of which the following will serve 
as an example : 

R. Ac. carbol. cryst., gr. ij 

Aquae, ^ iv. 

M. 

SiG. — Apply on lint or cotton thrice daily. 

Constitutional treatment, whether internal or external, is 
better not employed, save in exceptional cases, tintil the sub- 
sequent {secondary) symptoms appear, because in many in- 
stances it is impossible to diagnosticate the nature of 



56 VENEREAL DISEASES. 

the lesion under observation, and inasmuch as mercury, 
when given during the existence of the initial lesion, has a 
tendency to retard the outbreak of the secondary symptoms, 
it leaves the surgeon in donbt as to what the disease really is, 
and unable to tell his patient what or what not to expect. De- 
laying until secondary lesions come on, or until the period 
at which they should appear has passed, docs not injure the 
patients prospects of recovery, and it does give the surgeon 
the opportunity of informing the patient as to the nature of 
his disease. 

There are cases where it is necessary to cure the initial 
lesion rapidly, — as, for instance, in married people, — and to 
retard and, as far as possible, check the subsequent manifes- 
tations ; but in such cases the patient should be told that 
by so doing- the surgeon will be unable to tell him or her 
what subsequent symptoms to expect, or to count upon 
probable recovery, even after many months of treatment. 

These exceptions do not then conflict with this general 
law, viz. : Do not treat the initial lesion by the internal use 
of mercury, but await the development of secondary symp- 
toms. 

Internal treatment by tonics, iron, quinin, and the like is 
admissible 'in this stage should the patient be anemic, a very 
frequent condition in syphilis. 



CHAPTER IV. 

SYPHILIDES OF THE SKIN AND ITS 
APPENDAGES. 

In the last chapter we passed in review the initial lesion 
of syphilis, dwelling upon its characteristics and the main 
points of difference which exist between it and the chan- 
croid. This one I purpose to devote to considering the 
nature of the subsequent lesions which occur in syphilis, 
what are commonly known as the secondary and tertiary 
symptoms, more particularly those which occur upon the 
skin, reserving the syphilides of the mucous membranes until 
later on. 

In the first place, as regards the nomenclature : I wish 
you to remember that the terms secondary and tertiary are 
ones of mere convenience, and must not be accepted in a 
purely chronological sense. Many of the symptoms which 
are classed as tertiary may and do appear in the secondary 
period, — as, for example, the affections of the nervous system, 
— and should you be too bound down to name and rank all 
affections of the nervous system as necessarily tertiary, you 
will involve yourselves in much confusion and trouble. The 
true distinction I believe to be this, viz. : that during the 
secondary stage the symptoms are more superficial and more 
amenable to treatment than they are during the tertiary 
period, and that the exudations which occur during the earlier 
stage are absorbed and removed more speedily than those of 
the latter. In addition to this they have not the same de- 
structive tendency, for we shall find as we go on that the ter- 
5 57 



58 VENEREAL DISEASES. 

tiary lesions are marked by deep, and oftentimes serious, loss 
of tissue, while the secondary lesions are, comparatively 
speaking, mild, and leave behind no traces of their presence. 
I, therefore, much prefer to speak of these lesions as the 
superficial and the deep lesions of syphilis, irrespective of their 
seat, whether on skin or mucous membrane, in the eye, ear, 
nervous system, or bone. 

Before the symptoms upon the skin and mucous mem- 
branes appear there is a period of rest (ihciibatioti) between 
the occurrence of the initial lesion and the advent of the 
subsequent manifestations, during which time the initial lesion 
may have entirely healed, leaving only the induration of 
its former site and an induration of the nearest chain of glands 
as traces of its presence. Even these latter may be very in- 
distinct, rendering the connection between the two sets of 
symptoms vague and uncertain, and the relation each bears 
to the other would be overlooked unless you were fore- 
warned. Note, then, that there are two periods of incubation 
in the early stages of syphilis, the first being between the infect- 
i?ig coitus and the appearance of the initial lesion, and the 
second between the appearance of the initial lesion and the 
coming-on of the early syphilides. 

The length of this incubative stage varies within certain 
limits, as does the incubation of the initial lesion. For all 
practical purposes you may consider the maximum limit as 
about ninety days, or three months, the average being from 
forty-two to forty -five days, or between six and seven weeks. 
The minimum limit you may fix at twenty -five days, or be- 
tween three and four weeks, just about the length of the 
incubative period of the initial lesion. 

Formulate for yourselves, then, this rule : The early 
syphilides have, like the initial lesion, a period of incubation, 
the average length of which is forty -five days, but which may 



SYPHILIDES OF THE SKIN AND ITS APPENDAGES. 59 

extend to ninety, beyond which time it is rarely protracted, un- 
less it has been prolonged by the internal treatment of the ini- 
tial lesion with mercury. 

Before the early syphilides make their appearance there 
are certain vague and by no means constant symptoms 
which precede them by a few days, and which are known 
as ." prod/vmata." These are fever, rheumatoid pains of 
the muscles, aching of the bones, especially of the super- 
ficial long bones, such as the ulna and the tibia, and 
headache, usually confined to one lateral half of the head 
(liemicranid). The peculiar feature of these symptoms 
is that they come on at night when the patient is in 
bed, but not until the heat of the body has warmed the 
bed ; hence in those patients whose occupations oblige 
them to turn day into night, such as bakers, the pains come 
on in the daytime, when they are warm in bed — so it seems 
to be really the heat which brings out the pains and not 
necessarily the time. When the patients are up and about 
these symptoms vanish. During the fever there may also 
be a slight rise in temperature, although this is not con- 
stant. 

After the prodromata have lasted for a few days the syph- 
ilides make their appearance upon the skin and mucous mem- 
branes, and the first of these is known as the erythema syphi- 
liticum, or, as it is commonly called, "syphilitic roseola." 
Here I wish to protest against the names which have been 
usually given to these syphilides of the skin. They are rose- 
ola for the erythematous and psoriasis for the squamous 
eruptions, such as come upon the palms of the hands and 
soles of the feet, ecthyma and rupia for the pustular crusta- 
ceous manifestations of the later stages of syphilis ; and 
they are so named from the slight resemblance they have to 
the corresponding nonvenereal eruptions which appear on 



60 VENEREAL DISEASES. 

the skin. The objection I make to these names is that they 
are complicated a?id confusing, and I much prefer the no- 
menclature I shall presently give you as being simpler and 
more accurately describing their pathological condition. The 
names I propose for your use are : 

Erythematous, \ 

Papular, 

Pustular, and Syphilides. 

Tubercular / 

These again may be subdivided as follows : 

,-, ., ( Maculatum 

Erythema \ ^ . . 
J ( Papulatum. 

These also are called the macular and maculopapular syph- 
ilides. The papular syphilides are also divisible into the : 

f Miliares 
Papulae -j Lenticulares seu 
(_ Squamosa^. 

The pustular syphilides may also be divided into two 
groups, namely — 

Pustulae et 
Pustulocrustaceae, 

And the tubercular into — 

Tuberculae et 
Tuberculocrustaceae. 

In addition to these forms there is another variety, which 
is known as the gummatous syphilides, and this is further 
divided into the — 

XT , °/. \ Gummata, 
Nonulceratmg j ' 

according as they break down or not. 



SYPHILIDES OF THE SKIN AND ITS APPENDAGES. 6 1 

This includes all the varieties of the syphilitic manifesta- 
tions of the skin, and the advantage of these names is that 
they describe accurately the physiological conditions of the 
lesion and its cause at the same time. Thus, papulo- 
squamous syphilide, although a little longer name than 
syphilitic psoriasis, tells you more, and the same is true of 
pustular syphilides as against syphilitic ecthyma. I shall, 
therefore, in describing the syphilides of the skin use the 
foregoing' nomenclature, and the one which heads the list 
is the erythematous syphilide. 

Varieties. — Erythema maculatum ; erythema papula- 
turn. 

Synonyms. — Macular and maculopapular syphilides. 



Erythema Maculatum. 

This is the first one of the skin eruptions to make its ap- 
pearance, coming on about forty-five days after the initial 
lesion, and is characterized by rose-colored blotches, ?iot ele- 
vated above the surrounding skin, abundant over the entire 
trunk, arms, and legs, sometimes invading the face, notably the 
forehead, and occasionally being met with on the palms of 
the liands and on the soles of the feet. Just before the rash 
fully declares itself there is a peculiar mottling of the skin, 
looking as though the eruption were under the cuticle but 
had not yet made its way through. There may be at this 
time some nocturnal syphilitic fever, with a slight increase of 
temperature. One other symptom I have reserved, as I 
wish to dilate a little upon it, and that is, there is no itch- 
ing. Syphilitic eruptions do not itch, although the skin 
of syphilitics is often irritable, hence if you inquire of such 
if there be any itching, they will as likely as not reply in 
the affirmative, yet when you come to examine the skin 



62 VENEREAL DISEASES. 

there are no marks of finger-nails, such as are found in 
phthiriasis, eczema, lichen, etc. Do not, therefore, be 
thrown off your guard by any supposed itching of the 
skin in syphilis (of course, if lice are present, the case is 
different, but their presence and subsequent removal will 
explain and cure this symptom), although there may be, 
especially in women, an irritability of the epidermis. 

The erythematous syphilide pursues its course evenly and 
quietly, passing on from the distinct rose-colored stains to 
a coppery hue, then to a dingy yellow, and finally disap- 
pears entirely with a slight desquamation of the cuticle, leav- 
ing no trace of its presence. A few words about the cop- 
pery luce of the syphilides : Its diagnostic importance 
has been much exaggerated, and you will, in many non- 
venereal skin eruptions, see as much of the copper color as 
you will in the syphilides. 



Erythema Papulatum. 

This variety of erythema comes on after the macular 
kind, sometimes even before its entire disappearance, and 
seems to be the intermediate link between the erythemata 
and the papulae. It is raised above the level of the skin, is 
flattened and seated upon a broad base, is of a darker hue 
than its congener, the erythema maculatum, and is always 
more or less scaly. This desquamation in the syphilides is 
somewhat different from what takes place in the simple 
kinds of eruptions : it is rather a peeling than an actual 
scaling. It is less widely distributed than the macular kind, 
being found chiefly on the back of the neck, on the back, and 
on the volar surfaces of the arms and legs ; it also affects 
the palms of the hands and soles of the feet rather more than 
does the erythema maculatum. Not infrequently, as I have 



SYPHILIDES OF THE SKIN AND ITS APPENDAGES. 63 

already said, it is found conjoined upon the body with the 
macular variety ; indeed, in certain parts of the body where 
heat and moisture are found the macular seems rapidly to 
pass into the papular eruption. This is especially noticeable 
about the genitals of women, where these papules become 
quite luxuriant in their growth and secrete abundantly, tak- 
ing on the appearance of mucous patches, which indeed they 
really are ; perhaps you may recall several cases of the kind 
which I have already shown you in the wards. This variety 
paves the way to the next stage in the disease, where 
papules take the place of the erythemata. 

Varieties. — Papulae miliares ; papulae lenticulares ; 
syphilis squamosa. 

Papula Miliares. 

The course which the erythemata pursue varies some- 
what according to the intensity and the acuteness of the 
disease. Sometimes the erythemata will entirely disappear, 
leaving the skin unblemished, and this freedom from dis- 
ease may last for some weeks before the next step is reached. 
Here you see, then, a tendency to incubation even be- 
tween the various kinds of the eruption, but sometimes 
the attack is much more rapid than this, and before one 
form of eruption is gone another comes on, so that upon 
the same subject you will find macules, papules, and even 
pustules scattered over the body, constituting what is known 
as "polymorphism." Remember, then, that the papules may 
not appear until several weeks after the disappearance of the 
erythemata, especially if a mercurial treatment has been in- 
stituted, or it may come " zvith a rush," so to speak, one 
trai?i of symptoms crowding upon the other, leaving no inter- 
val of repose or apparent freedom from the disease. We 
will suppose that the macules have disappeared and that 



64 VENEREAL DISEASES. 

the papular stage is due ; what must we look for ? The 
nocturnal pains which had almost disappeared now return, 
and there may be some fever, when suddenly, over the en- 
tire body, arms, legs, face, and scalp, small pointed elevations 
of a reddish color break out, which are closely packed to- 
gether, and are sometimes crowned at their apices with a 
minute scale. These go on for several weeks, getting more 
and more purple in hue ; the papules become more scaly, 
less elevated, and finally disappear, leaving a staining, 
which, from being at first purple, becomes a yellowish- 
brown, and this in its turn is absorbed, leaving the skin free 
from scar or blemish of any kind. These papules are small 
and bear some resemblance to the simple acne which invades 
the face and shoulders, save that they are much more numer- 
ous ; hence the name sometimes given it, of acne syphilitica. 
One peculiarity about this eruption — indeed, you may say 
about all the syphilitic eruptions — is a tendency to assume a 
circular form, grouping itself into the shape of a ring, or 
segments of a ring, over the body, having sound skin 
within the circumference of the circle or between the segments 
of the same, and this is kept up even into late stages of the 
disease. 

When these papides are seated upon the forehead, they 
assume somewhat the appearance of a ribbon or band 
stretched from temple to temple, and among the older 
syphilographers the eruption received the fanciful name 
of "corona Veneris" a by no means inapt title. These pa- 
pules extend into the hairy scalp, where, from irritation of 
the comb and finger-nails, each apex becomes covered 
with a bloody scab, somewhat resembling the disease of 
the scalp called impetigo capitis. We shall see the same 
thing occur in the pustular stage of syphilis, except that 
there the crust is larger and thicker. 



syphilides of the skin and its appendages. 65 

Papul.e Lenticulares et Squamos/e. 

After the miliary papules have run their course, some- 
times even before, the next variety of the same eruption, the 
lenticular, manifests itself in the shape of broad, flat papules 
considerably raised above the surface of the skin, of a color 
similar to the preceding eruption, but covered with a thicker 
and darker scale which occasionally becomes transformed 
into a very thin crust, due to exudation from the papule 
itself. These papules are not widely disseminated over the 
body as are the erythemata or the papulae miliares, but are 
found in isolated groups upon the palms of the hands and 
soles of the feet, between the fingers audioes, upon the genitals 
of both sexes, at the angles of the mouth, where they are 
frequently continuous with mucous patches of the buccal 
cavity, at the edge of the hairy scalp, upon the shoulder- 
blades , on the buttocks and thighs. When grouped to- 
gether, as they often are, and covered with scales, they 
bear some resemblance to patches of psoriasis vidgaris, 
but in this latter disease the scales are of a more silvery 
white color, and are smaller than is the case in syphilis. 
When found upon the genitals and between the toes, the 
heat and moisture of the parts favor their growth and 
development ; they lose their scales, and the secretion which 
exudes from them covers their surfaces with a dirty white 
layer, which can be wiped off, revealing a glazed, red floor. 
These are usually the lesions which have been described as 
mucous patches of the skin, but which the Germans more 
accurately call the " moist secreting papule." 

When seated at the junction of mucous and cuta?ieous 
surfaces on the genitals, the papules retain very much the 
same cliaracteristics as the mucous patch, but at the angles 
of the mouth the skin-lesion, from exposure, is covered with 



66 VENEREAL DISEASES. 

a dry scale, sometimes a thin crust, while the lesion of the 
mucous membrane is moist and covered with a whitish 
pellicle. 

But it is to their position upon the palms and soles that 
I wish to invite your special attention. In the beginning 
of their growth the papules are broad, flattened, and of a 
deep purple color, the apices are covered with scales, which 
are renewed as soon as they get rubbed off. Later on 
these papules coalesce and form broad patches, which become 
fissured and bleed, and the blood mingled with scales forms 
a thin crust upon the surface of the lesion. These patches 
extend in size, become very mucli thickened, and, covered as 
they are with scales and dried blood, are often with diffi- 
culty distinguishable from chronic eczema of the palms of 
the hands. But I beg you to bear in mind that this latter 
affection is, in my experience, a rather uncommon disease, 
whereas a papular syphilide of the palms is not infrequent. 
Of course, when you are able to get a history of syphilis, 
the nature of the lesion is clear, but sometimes you may 
get none, perhaps can not ask for any, and in such cases it 
will stand you in good stead to remember that nine times 
in ten such lesions of the hands and feet mean syphilis. 

Formulate, then, this rule : Squamous affections of the 
palms of the hands and of the soles of the feet are nearly 
alzvays syphilis and reqidrc antisyphilitic treatment. 

We are now nearing the boundary-line which is supposed 
to separate the secondary and tertiary lesions, and heretofore 
we have noticed no tendency to ulcerative destruction ; all 
the lesions disappear and leave no trace behind them. But 
in the next stage this is changed : pus is formed, and pus 
means destruction of tissue. The lesions which we are now 
to consider I have divided into two groups, the pustidar and 
the pustulocrustaceous — i. e., those which remain pustular^ 



SYPHILIDES OF THE SKIN AND ITS APPENDAGES. 6j 

not becoming covered with a crust, but being absorbed, and 
those which break down and are covered with a scab. 
Varieties. — Pustulae ; pustulae crustaceae. 



Pustule. 

. This variety begins differently from any which we have 
heretofore examined, having its seat more deeply embedded 
in the tissues than the papule, and starts from the true 
skin and not in the epidermis. It is the kind known 
as impetigo syphilitica. Starting then from the deeper 
layers of the skin, it is felt beneath the surface as a small, 
hard point, which rapidly becomes elevated and is crowned 
at its apex with a pustule. This pustule increases in size, 
and may occupy the entire base upon which it is seated, said 
base being surrounded by a purple areola, while the pustule 
itself is yellow. This pustule is fidl, round, and in the 
majority of cases distended with matter, which, if the pus- 
tule is broken, dries into a small superficial crust, revealing, 
on removal, a slight ulceration beneath. Moreover, this 
pustule is not umbilicated, as is the case in variola. Pro- 
vided the course of the disease is favorable, the pustule 
dries up and becomes covered with a few flakes of dried 
epidermis ; these are subsequently cast off, and a discolora- 
tion of the skin remains. After a longer or shorter time 
this staining fades away, and unless the pustule has started 
from deep down in the tissues, no scar is left behind. If its 
origin has been deep-seated, after the pigmentation vanishes 
a white scar is visible, corresponding to the size of the pus- 
tule, and is due to an atrophy of the cellular tissue beneath 
the skin. This is not so marked as it is in the crustaceous 
syphilides. 

These pustules are widely scattered over the body, the 



68 VENEREAL DISEASES. 

head, face, trunk, arms, and legs being invaded, resembling, 
in this respect, the erythematous and papular syphilides. 
This variety may be succeeded by another crop of pustules 
of the kind I have here designated as crustaceous, and which 
are more serious than the ones we have just studied, inas- 
much as they are always attended by ulceration, sometimes 
qidte extensive, and are not so amenable to treatment. 



Pustule: Crustacea. 

The pustulocrustaceous syphilides commence with a 
more pronounced and more diffiiscd amount of exudation 
beneath the skin than do the nonulcerating pustules ; they 
come rapidly to the surface, the pustule breaks, and when it 
does, an ulceration more or less extensive is found beneath. 
Sometimes this ulceration does not penetrate deeply into the 
tissues, but spreads laterally over quite an extent of surface, 
secretes abundantly, and presents irregularly shaped borders 
(scalloped), due to the coalition of several individual pus- 
tules or groups of pustules. This is known in the books 
as syphilitic ecthyma. At other times the pustule increases 
enormously in size, ulcerates, and the ulceration extends 
deeply into the tissues, making a punched-out cavity, which 
is covered over by a thick, brown or black crust, due to the 
admixture of blood with the pus. This crust continually 
increases in height by accretion, at its base, of fresh matter 
from destruction of tissue, and forms over the ulcer a 
conical scab, from one-half to two inches in height, which 
is firmly mortised into what seems to be sound skin, but 
which, on removal of the crust, is seen to be undermined 
by the ulceration. This undermining of tissue is also found 
in the so-called ecthymatous variety, but in a much less 
degree. This is the rupia of the books, one of the worst 



SYPHILIDES OF THE SKIN AND ITS APPENDAGES. 69 

forms of the syphilides you will be called upon to deal 
with, and which is frequently rebellious to treatment. 

The seat of both varieties is more limited than is that 
of the nonulcerating pustules, which, when they appear, are 
more likely to be discrete. The face, the upper arm, the 
thighs, and the buttocks are their favorite situations, although 
they are sometimes found upon the trunk, especially the back. 

Varieties. — Tuberculae ; tuberculocrustacese. 

Closely conjoined with the pustulocrustaceous syphilides 
in nature and course are the tuberculocrustaceous erup- 
tions. They affect the same portions of the body as the 
former, and only differ at their commencement in being 
larger and harder, and may be regarded as the connecting 
link between the pustule and the gumma. The idceration 
which ensues runs much the same course as in the so-called 
rupia — is deep, destructive, and often rapid, the crust is thick 
and elevated, and in its subsequent course is not to be dis- 
tinguished from its congeners of the pustular variety. 
When I come to speak to you about the syphilitic affec- 
tions of mucous membranes, I shall show how, under cer- 
tain conditions, these ulcerating syphilides may be mistaken 
for chancroids. 

Varieties. — Ulcerating and nonulcerating gummata. 

The next and last symptom to be spoken of is the 
gumma (PL, gummata), in which the amount of infiltration 
into the skin and cellular tissues is very abundant and 
brawjiy, and if it breaks down, gives rise to a very serious 
and nasty-looking ulceration. Two varieties of this gum- 
matous infiltration exist, the diffuse and the circumscribed, 
and both kinds, if left untreated, will idcerate. The result- 
ing sore is deep, has a tendency to burrow, has a yellowish 
floor covered with the remains of dead and dying tissue, and 
secretes abundantly — in many of these points resenzbling a 



70 VENEREAL DISEASES. 

chancroid, but in their nature they are entirely dissimilar. 
A chancroid becomes worse under a mercurial course ; this is 
poison to it, while in the lesion under consideration mercury 
is the only thing that will do it permanent good. 

In addition, the differential diagnosis may also be assisted 
by a microscopical examination of the secretion of the gumma 
to detect the presence or absence of the streptobacillus of 
Ducrey or of the bacillus of Lustgarten. Should the former 
be present, the probabilities would be in favor of the lesion 
being chancroidal, although its absence would not necessa- 
rily indicate that the lesion was gummatous ; its nature, 
therefore, would be determined by other characteristics. 

These gummata are found upon the thighs and arms 
more frequently than they are elsewhere, and are single 
rather than multiple, although they may be associated with 
gummata in the viscera and in the mucous membranes. When 
patients have arrived at this stage of visceral syphilis, a 
very peculiar condition of the system supervenes : what 
is known under the name of syphilitic cachexia. In this 
stage they steadily but surely run down, the functions are 
no longer active, assimilation either of food or medicine 
ceases, and death supervenes from exhaustion. Happily 
such cases are rare, but their occurrence serves to show 
what syphilis is capable of doing. 

We have now finished the study of the lesions known as 
syphilides of the skin, and I have given you their salient 
points without burdening your minds with unnecessary 
details. I have passed over in silence two -varieties : the 
vesicidar and the bidlous syphilides which are described 
in some treatises on venereal diseases. I omit them 
for two reasons — first, because I doubt their separate ex- 
istence (both of them really belong to the pustular syphi- 
lides) ; and, secondly, if they do exist, they are so very 



SYPHILIDES OF THE SKIN AND ITS APPENDAGES. 7 1 

rare as to make them curiosities of syphilis rather than 
regular lesions, and my object in this book is to avoid 
undetermined points and to give you only what is practical 
and certain. But before passing on to a consideration of 
the effects of syphilis upon the appendages of the skin I 
wish to say a few words as to the general course which the 
cutaneous syphilides pursue. 

In the first place, after the initial lesion has passed away 
there may be a period of apparent immunity from the dis- 
ease before the syphilides appear ; this I have already told 
you is the period of incubation between the so-called prim- 
ary and secondary stages. The erythemata appear and 
disappear, leaving another intermission between the erythe- 
mata and the papulae, and this period varies from two 
weeks to one or two months, according to the activity and 
efficacy of treatment. After the subsidence of the papules 
another period of repose of several weeks may occur 
before anything further appears, when some variety of the 
papular syphilides will recur, or, if the disease is progress- 
ing, pustules will show themselves. So it goes on, each 
stage advancing progressively from superficial to deep 
lesions — from those symptoms which are mild and which 
are readily absorbed to those which are ulcerative, de- 
structive, and which are not absorbed. 

But, in place of advancing, we will suppose the disease 
yields to treatment ; what do we see then ? The erythema 
vanishes, and the patient, though kept under observation 
for some time, displays nothing more ; or, at the end of 
several months, he may show a slight recurrence of the 
erythema, or perhaps a few scattered papules. Treatment 
is vigorously pushed, the papules disappear, and the patient 
hears nothing more from his syphilis. He is, to all intents 
and purposes, well. But there is one point I wish to lay 



72 



VENEREAL DISEASES. 



stress upon : syphilis never runs a haphazard course ; it 
never begins with deep-seated lesions first, to show later on 
superficial ones, but it pursues, if a serious case, a pretty 
steady course from bad to worse ; if, on the contrary, it 
be a mild case, occasional relapses of the same kind of 
eruption may occur, but it never skips about. I shall revert 
to this point again w T hen I come to speak of the prognosis. 
As regards the course these lesions pursue, you may lay 
down this broad general principle : the superficial lesions 
disappear quite quickly, the deep-seated ones quite slowly. 
In order that you may readily comprehend this, I append 
here a table giving approximately the time after the ap- 
pearance of the initial lesion at which the various syphilides 
are due and their duration : 



Name. 


Due. 


Duration. 


Erythema, . . 
Papules, . . . 
Pustules, . . . 
Gummata, . . 


6-12 weeks. 
2-6 months. 
6-15 months. 
1-5 years and more. 


3-6 weeks. 

4-8 weeks. 

2-4 months and more. 

^-2 years and more. 



As appendages of the skin, the hair and the nails invite 
our attention, and of the former there are two varieties 
of syphilitic disease known as alopecia, one of which occurs 
in the early, and the other in the late, stage. The early 
alopecia is the more general of the two, not being confined 
to the hairy scalp, its usual seat, but attacking the hair of 
the face, and even of the entire body. I have seen one case 
where the patient lost all the hair of his head, face, and 
body. This seems to be due to changes going on in the 
hair bulbs themselves, and not to any changes in the follicles, 
so that the hair grows again as luxuriantly as before. This 
is not the case in the late stage, when the lost hair is not 



SYPHILIDES OF THE SKIN AND ITS APPENDAGES. 73 

generally replaced, and this is due to disease of the follicles 
themselves, as well as to their destruction from deep ulcera- 
tions of the scalp, face, etc. 

The early alopecia is coincident with the erythematous and 
papular, the late with the pustular and tuberculocrustaceous, 
eruptions. 

• The affections of the nails belong to the late stage of 
syphilis, and are usually concomitant with the pustular 
lesions. During the existence of the papulosquamous 
syphilides, however, the nails of fingers and toes are some- 
times affected : they crack, the edges become ragged and 
uneven, and at times scaling of the surfaces takes place. 
But later on in the disease pustules occur in the matrix of 
the nail, causing detachment, and the nail drops off. After 
this happens the ulceration of the matrix may continue, 
destroying it and with it all hope of a renewal of the nail. 
If the ulceration is checked before this stage is reached, the 
nail may be reproduced ; but its growth is very slow, the 
new nail is brittle, uneven, and ragged, and is seldom of 
much use. 



CHAPTER V. 

SYPHILIDES OF MUCOUS MEMBRANES- 
SYPHILITIC ADENITIS. 

Following naturally upon the syphilides of the skin 
come the sypliilides of mucous membranes, and these are 
among the most common of all the affections of the earlier 
stages of the disease, as well as the most obstinate to treat. 
They recur again and again y often being the 07ily symptom 
of syphilis which remains after the first outbreak has 
passed away, and are frequently a source of more annoy- 
ance to the patient than any of the manifestations upon the 
skin, unless they be those of the face. 

Like the syphilides of the cuticle, the syphilides of the 
mucous membranes are divisible into the superficial and the 
deep kinds, the former of which are not in themselves 
serious; the latter are of extreme importance, from the 
consequences which they entail by destruction of tissue. 

Coincident with the outbreak of the erythema maculatum 
the patient will complain of a feeling of soreness of the 
throat and dryness of the fauces. Inspection reveals the 
entire mucous membrane of a congested, red color, or, as 
occasionally happens, having spaces of sound mucous 
membrane between the congested spots, and resembling, 
in many respects, the eruption upon the skin. 

Sometimes this erythema is continuous upon the mucous 
membrane of the tongue and the entire buccal cavity, and 
so general is it that it may be mistaken for a scarlatinal 
sore throat, particularly if the syphilitic fever has been at 

74 



- SYPHILIDES OF MUCOUS MEMBRANES. 75 

all high. But a little attention to the other symptoms will 
save the physician from such a mistake, and the treatment 
will definitely settle the doubt. The sides of the tongue are 
dotted with small punctate spots, giving it somewhat the look 
of a ripe raspberry, and it has quite a peculiar appearance. 
With all this congestion there are very few physical symp- 
toms : the voice is not materially changed, the breatJiing is 
not impeded, nor is deglutition dijficidt. The tonsils are some- 
times enlarged, and can be felt externally as well as seen 
internally, and the glands of the posterior and anterior 
cervical regions are indurated and slightly enlarged. In 
addition to these sets of glands the following may also be 
implicated : the anterior and posterior auricular, the sub- 
mental, and the submaxillary. 

This erythema of the mucous membranes disappears in 
the same time and manner as the erythema of the skin, 
only as the parts are protected from the air, no desquama- 
tion occurs. The congestion tones down from purple to 
red, the red to the normal pink hue of mucous membranes, 
and no vestige of the disease is left. 

Here, also, as with the syphilides of the skin, we may 
have a period of rest and freedom from symptoms, but of 
all the manifestations of the earlier stage of syphilis this is 
the most persistent, and the patient will hardly get rid of 
one crop of eruptions before another crop is ushered in, 
and that, too, while treatment is going on. Sometimes this 
may be a relapse of the erythema faucium, or it may be a 
form which I am now about to describe. 

The patient consults the surgeon for a soreness of the 
throat, resulting, as is frequently stated, from cold, con- 
joined with "fever-sores" upon the tongue and mucous 
portions of the lips and cheeks. An examination shows the 
mucous membrane of these parts slightly thickened, as 



j6 VENEREAL DISEASES. 

though from infiltration of the parts, and on the surface 
are seated opaline \ glistening patclics of a white color, devoid 
of any true ulceration, and usually sensitive to the action 
of hot and cold drinks, pungent condiments, etc. This 
tenderness is especially noticeable when the lesions are 
seated upon the tongue or lips. Associated with these 
mucous patches there may be found upon the body a 
papular or papulopustular eruption, but very often there 
is nothing at all except the lesions of the mucous mem- 
branes upon which to found a diagnosis. I know of few 
points in syphilis more puzzling to decide upon than these 
same mucous patches, particularly where patients insist 
that they are associated with a disordered condition of 
the stomach, when for want of certainty as regards history 
and antecedents the surgeon falls into the error of consider- 
ing them as simple " aphthae." 

The white covering of the mucous patches is closely 
adherent to the tissues below, and it can not be detached 
without causing some slight Jiemorrhage ; indeed, in some 
cases this white film is really below the surface, and is an 
actual infiltration into the submucous tissues with external 
ulceration. 

This form of mucous patch is extremely obstinate, and 
recurs repeatedly upon the same spot or upon adjacent parts 
of the membrane. Gradually, however, under active and 
persistent treatment the lesions disappear, it may be for 
good, or else they reappear in another form corresponding 
to a more advanced stage of the disease. 

This variety is specially to be found in the throat, its 
favorite habitat being the tonsils and the posterior arches of 
the palate. Occasionally it is found upon the dorsum and 
sides of the tongue, less frequently upon the buccal mucous 
tissue. Its first appearance is a slight elevation of the 



SYPHILIDES OF MUCOUS MEMBRANES. J J 

membrane from infiltration into the submucous tissue, but 
this does not last ; the elevation breaks down and is con- 
verted into an ulceration varying in depth according to the 
infiltration. 

The floor is uneven and gray in appearance, and the secre- 
tion is not very abundant. But little inconvenience results to 
the patient from the presence of these lesions, as the parts 
become callous from the infiltration and thickening of the 
tissues, and the ulcers are not sensitive to heat and cold, as 
they were in the earlier stage. These ulcers have a ten- 
dency to extend slowly, it is true, but still deeply, and when 
they are seated upon the tonsils or behind the posterior 
arches of the palate, they become of quite large size. It 
is at this stage that a change in the character of the voice 
takes place, and the usual clear tone is exchanged for a 
hoarse whisper or an uneven strident sound. An examina- 
tion by the laryngoscope shows ulceration of the mucous 
membrane of the larynx and of the false vocal cords with 
edema. On attempted phonation it is seen that the true 
cords do not come evenly together, hence the timbre of the 
voice is materially altered. 

Succeeding this stage, sometimes merging into it, is the 
true ulcerative syphilide of mucous membranes, due to the 
breaking-down of the gumma, which forms in the sub- 
mucous cellular tissue. The first thing to attract attention 
is a diffuse brawny swelling of the soft parts, which pro- 
gresses rapidly, breaks down, and, when it occurs in those 
portions of the body that act as septa between cavities, it 
produces important and irremediable destruction. The action 
is rapid in these cases, a few days being oftentimes sufficient 
to cause extensive disfigurement. I shall return to this 
topic when I come to speak upon the syphilis of special 
organs. 



7 8 VENEREAL DISEASES. 

In the last chapter I spoke to you of cases in which 
ulcerating gummata of mucous membranes might be mistaken 
for chancroids. A patient who has been the subject of an 
old and long standing syphilis will present himself to the 
surgeon with a circumscribed hard tubercle seated upon the 
mucous membrane of the penis, either in the fossa glandis, 
on the reflex layer of the prepuce, or at the junction of the 
frenum with the fossa. This tubercle is perfectly painless ■, 
unattended with any inflammation, and apparently indolent 
in character. It will suddenly break down, become con- 
verted into a deep, punchcd-out ulcer, corresponding in ex- 
tent with the original tubercle, presenting a yellow, uneven 
floor, devoid of induration, and secreting a thin, viscid 
fluid, which, from irritation, will become purulent. If this 
lesion be seen for the first time in the ulcerated stage, it 
may readily be mistaken for a chancroid, especially as it 
evinces destructive tendencies, for it may eat away the 
frenum, burrow into the urethra, and extend far beyond the 
limits of the gumma which gave it birth. These are puz- 
zling cases to decide upon ; the history will sometimes help 
you to a diagnosis, but of all things the treatment will be the 
experimentum crucis. 

Although the result of treatment will be the crucial test, 
you should not omit to make microscopical examination in 
these cases if, peradventure, you may detect either the 
streptobacillus of the chancroid or the bacillus of L ustgarten, 
which he claims to have found in gummous ulcerations as 
well as in the sclerosis of the initial lesion and in the 
mucous patches. Should you find either one of these two, 
it will be strong confirmation as to the character of the 
lesion, but you must not count too strongly upon positive 
results from your examination. My own experience is that 
these bacilli are difficidt of detection. 



SYPHILIDES OF MUCOUS MEMBRANES. /O, 

The ordinary remedies for chancroid are useless : cautery 
and local dressings do not produce the results they should, 
and you begin to despair. Change your tactics, and with- 
out giving up topical applications, except the cautery, put 
your patient upon a mixed treatment (mercury conjoined 
with the iodide of potassium), and the result will, I know, 
gratify you ; the lesion will get well. 

Conjoined with these symptoms of the skin and mucous 
membranes during the earlier stages of syphilis are others 
fully as important for you to know about and remember. 
I refer to the enlargement of the glands over the entire 
body, which goes under the name of adenitis universa- 
lis. You remember, when we were studying the initial 
lesion, I called your attention to the induration of the chain 
of glands nearest to the lesion, and told you at the time 
how important it was. As the period arrives for the out- 
break of the subsequent lesions the glands all over the 
body — the anterior and posterior cervical, the submaxillary 
and submental, the anterior and posterior auricular, .the 
occipital, the epitrochlear, and the inguinal glands — are 
found enlarged and indurated. This manifestation is co- 
incident with the erythema cutis et faucium and with the 
alopecia which mark the early stages of syphilis. Under 
treatment these indurated glands slowly subside, but their 
subsidence is very gradual, and if the result has been very 
good, no trace is left behind ; but usually a slight hardness 
remains even after the patient has entirely recovered from 
his illness, sufficient to show the practised finger that 
trouble has existed. 

This induration differs very widely from the brawniness and 
hardness which obtain with some chancroids. The condition 
of the glands found with the chancroid you are already fa- 
miliar with, but with the adenitis in this stage of syphilis you 



SO VENEREAL DISEASES. 

are not conversant. In the first place, the glands are pain- 
less ; secondly, they are unattended with acute inflammation ; 
and thirdly, they do not suppurate. They appear as round 
kernels, from the size of a small buckshot to that of a 
large pea, lying just beneath the skin, and upon handling 
they roll about quite freely under the tissues. This con- 
stitutes the form of infiltration of glands which occurs during 
the early stages of syphilis ; in the later stages of the dis- 
ease another variety occurs, which is entirely different in its 
course and nature. This is called the gummous infiltration 
of glands, and resembles in a slight degree a cliancroidal bubo, 
just as the broken-down gummata of the penis will simu- 
late a chancroid. The swelling begins as an infiltration, 
not only of the gland itself, but of the circumglandular 
tissue, which becomes tense and brawny t and breaks dowit 
unless its course be checked by proper treatment. There 
is one very notable point in this breaking down : the skin 
covering the swelling opens in several places, and what comes 
from the enlargement is not pus, but a thin, sticky, colorless 
fluid not unlike thin gum. This exudation is not abundant 
at any one given time, but comes away continuously , and its 
discharge does not materially diminish the size of the swell- 
ing. 

This completes the circle of symptoms of the skin and 
mucous membranes likely to be met with in the average 
cases of syphilis which will fall to your lot, as practising 
physicians, to treat. But there are other lesions to which I 
wish to call your attention, fully as important as any you 
have heretofore studied, the consideration of which I shall 
reserve for a separate chapter. 



CHAPTER VI. 

SYPHILIS OF SPECIAL ORGANS. 

The lesions we are now to consider are those which 
affect the special senses of sight, hearing, smell, and genera- 
tion ; and as most of them occur in the late and more 
dangerous stages of syphilis, a correct knowledge of their 
natural history and course is important. 

Commencing with the eyelids, we find that the skin and 
mucous membranes of these organs are sometimes the 
seat, during the early stage in syphilis, of the initial lesion 
and of mucous patches ; but as these symptoms do not 
differ in their general character from those found elsewhere 
upon the body, they need not detain us. During the later 
stages the lids may also be attacked by pustules or gum- 
mata, which pursue the same course that similar lesions 
do elsewhere ; and the description which I have given in 
the two previous chapters will answer for these lesions of 
the lids. 

When the initial lesion or mucous patches are seated upon 
the palpebral conjunctiva, some inflammation of this tissue 
may ensue ; but it is usually very slight and limited in 
extent. 

The ocular and palpebral conjunctiva? may be the seat of 
other lesions, to wit : syphilitic papules and gummatous 
infiltrations ; the latter of these is perhaps the most com- 
mon. 

Until within recent years the acquired form of syphilitic 
keratitis, or inflammation of the cornea, was not clearly 
7 81 



82 VENEREAL DISEASES. 

recognized. It is not a common affection in this variety, 
although it is frequently met with in congenital syphilis. It 
occurs as opacities of the cornea seated in Descemet's mem- 
brane. The punctate variety is very rare in the acquired 
type. 

The sclera also may be the seat of trouble, and usually 
presents itself as one of three groups : epi- or periscleritis, 
scleritis parenchymatosa, and scleritis gummosa, the first two 
being varieties of the same form of inflammation. They 
may occur alone, being confined to the sclerotic, or they 
may be associated with secondary changes in the cornea, iris, 
or in the ciliary body ; the latter, or gummatous variety, is 
the most common. It commences usually near the edge of 
the cornea as a slight elevation over or close to the insertion 
of the external rectus muscle ; is of a deep-red or livid color, 
smooth, and covered, unless ulceration takes place, with 
sound conjunctival membrane. There is very little, if any, 
pain, nor is there usually photophobia, photopsia or much 
periplieral inflammation. It runs its course slozvly and 
quietly and ends in one of two ways : either by idceration 
or by resolution. 

One of the most serious syphilitic lesions of the eye is 
what is known as iritis, or an inflammation of the iris ; and 
this is doubly dangerous because, from its close relation with 
the ocular vascular tunic, — the choroid, — the disease is 
liable to invade the deeper tissues and result in serious con- 
sequences to vision. 

This symptom usually comes on about the sixth month 
of the duration of the syphilis, — sometimes, however, as 
early as the third, — and is associated with a syphilide of the 
skin and mucous membranes. It commences with what 
the patient calls a " zveakness of the eye," which, upon 
examination, is found to be very much congested, and this 



SYPHILIS OF SPECIAL ORGANS. 83 

congestion is present not only in the vessels of the con- 
junctiva, but of the sclera also. It is more marked close 
to the border of the iris, near the cornea, and is attended with 
lachrymation and photophobia. Upon close inspection the 
iris of the affected eye is seen to be of a dtdl, hazy color, to 
have lost its lustre, and it looks as though it were infiltrated 
with fluid. The pupil is small and contracted ; and if a few 
drops of atropin be dropped into the eye, the opening will 
be found irregular in shape, and the pupillary margin of 
the iris bound down to the anterior capsule of the crystalline 
lens. 

Note, then, these points in syphilitic iritis : 

First, congestion of the vessels of the conjunctiva and 
sclera ; second, lachrymation ; third, photophobia ; and 
fourth, adherence of the pupillary margin of tlie iris to the 
anterior capsule of the lens. 

In addition to these symptoms the patient complains of 
a severe supra-orbital pain, which, although present during 
the day, is more intense at night, depriving him of rest and 
sleep. 

It seldom happens that both eyes are attacked simultane- 
ously : the usual course is for one eye to be affected first ; 
as the disease subsides in that, the other one succumbs, 
and upon its recovery the first one is a second time 
attacked — constituting what is known as a u see-saw iritis." 

This is the variety which generally occurs in the early 
stage of syphilis ; but later on another kind appears, which 
is still more seriotis. The congestion, lachrymation , photo- 
phobia, and supra-orbital pain are again present in a more 
intensified 'form ; the infiltration is more marked ; and at the 
pupillary margin of the iris, apparently springing from the 
uvea iridis, an irregularly shaped nodule is seen which pro- 
trudes into the anterior chamber, sometimes completely 



84 VENEREAL DISEASES. 

blocking up the pupil. This nodule may break into the 
anterior chamber, and it then discharges a peculiar look- 
ing Jloccu/ent fluid, which is not pus , but gummatous matter. 
This form of gummatous iritis is often conjoined with a 
pustular eruption upon the skin, or with gummata of some 
portion of the body. 

Under proper care and treatment the inflammation and 
congestion subside, the iris assumes its normal color, and if 
the adhesions have not been very firm, the pupil regains its 
normal contour; but too frequently the adhesions are per- 
manent, and the pupil, particularly when dilated by atro- 
pin, shows an irregular border. This may not, however, 
be a serious matter, nor does it necessarily affect the vision. 

In the next stage, however, matters are different. As the 
disease progresses the deeper tissues are affected, the choroid 
becomes implicated, and the patient complains of dimness 
of vision, photophobia, and deep-seated pain in the eye. Ex- 
amination shows the normal range of vision diminished, and 
the ophthalmoscope reveals infiltration of the choroid, 
haziness of the choroidal and retinal vessels, with pigmentary 
deposits in the choroid, and, later on, atrophy of the chor- 
oidal tunic takes place, leaving the sclerotic visible beneath. 
This affection of the choroid is very often accompanied 
with an inflammation of the ciliary body, known as cyclitis, 
which is usually apparent as a ring of congested vessels sur- 
rounding the iris about its conjunctival border. It may or 
may not be associated with iritis. The symptoms become 
much aggravated, pain and photophobia are increased, and 
the patient complains of a marked diminution in vision with 
a feeling as though he were looking through a veil. If an 
ophthalmoscopic examination of the eye be made, it will 
be noted that the vitreous humor is hazy, opaque, and filled 
with shreds and coagula which float about, rising and fall- 



SYPHILIS OF SPECIAL ORGANS. 85 

ing according as the patient looks up or down. This is 
known as hy otitis, and this hyalitis is sometimes associated 
with opacity of the anterior capsule of the lens. 

The retina may also share in the disturbances which 
have invaded the other portions of the eye, and the symp- 
toms which occur are loss of vision with deep-seated pain. 
The ophthalmoscope shows a general hazy and indistinct 
look to the retina ; the vessels are blurred and diminished in 
size, especially the arteries, while the veins themselves may 
be larger than usual, and this is especially the case if the 
original attack be complicated with an inflammation of the 
sheath of the optic nerve, known as neuritis. Under these 
conditions the retina has a boggy look, as though it were 
infiltrated with fluid. If a gummatous infiltration be seated 
along the sheath of the nerve or in the brain tissue sur- 
rounding the nerve, we then find the optic nerve prominent 
and congested, to be later on followed by atrophy and a 
cupped condition of the optic nerve. 

These deep-seated affections of the eye in syphilis are 
very important, as unless they are promptly treated blind- 
ness may result. 

Besides these affections of the eyeball proper, the carnn- 
cnloz lachrymales and the lachrymal gland may be the seat 
of gummata. These affections are attended by swelling of 
the parts, which may, under treatment, disappear, or it may 
break down and leave an ulceration similar to other ulcerat- 
ing gummata of the skin. 

The syphilitic affections of the ear are not so well under- 
stood as are those of other parts of the body. The auricle 
and external auditory canal may be the seat of mucous 
patclies, and this variety of lesion belongs, of course, to 
an early stage. In addition, the middle ear may also be 
affected in the early as well as late stage, and this is due to 



86 VENEREAL DISEASES. 

a probable infiltration of the mucous lining of the middle 
ear, as well as to an extension of the disease from the 
throat along the Eustachian tubes. The symptoms com- 
plained of are a feeling of tension in the car ; sometimes 
tinnitus aurium, although this is not constant ; and a 
diminished power of hearing. These are frequently asso- 
ciated with nocturnal ' hemicrania and the early syphUides of 
the skin and mucous membranes. The speculum may 
show no trouble of the tympanum, or at the most a soggy 
condition of this membrane, with a slight sinking of the 
drum-liead. This early lesion is not usually serious, as the 
symptoms pass off without affecting audition to any marked 
degree. 

But when syphilis invades the deep portions of the ear, — 
the labyrinth and cochlea, — then you may expect serious 
trouble, and the patient can consider himself lucky if he 
retains even a portion of Ids hearing. In such cases the 
symptoms are vague and ill defined, being limited to pain in 
the head, which is not specially nocturnal in character, and 
occasionally tinnitus aurium. These continue for a longer 
or shorter time, when the patient suddenly wakes up some 
morning to find himself completely deaf. This peculiarity of 
suddenness in the attack is one worth your study, for you 
will find, when you come to examine other cases of nervous 
syphilis, that the same trait is present. The deafness is com- 
plete : the watch and tuning-fork, when pressed against the 
ear, convey no sound, and very often the same is true when 
these instruments are pressed against the bones of the skull 
or the teeth. I need hardly tell you that in such cases 
the prognosis is not favorable. The cranial pain is frequently 
severe, and is not confined to any one portion of the head, 
sometimes being occipital, sometimes frontal, and at other 
times it is vertical or basilar. The tinnitus is the most 



SYPHILIS OF SPECIAL ORGANS. 8? 

distressing symptom in these cases, and is extremely re- 
bellious to treatment, lasting even after a portion of the 
hearing power has been restored. 

The nose and air-passages, in common with the rest of 
the body, are liable to invasion from this infernal disease, 
which spares no tissue of the human frame but preys on 
all alike. In the early stage of syphilis the nasal mucous 
membrane becomes congested, and is the seat of mucous 
patclies both in its anterior and posterior portions. These 
manifestations yield readily to treatment, and produce only 
slight discomfort ; but as the disease progresses the parts 
are attacked by ulceration, with or without necrosis of tlie 
nasal and palatine bones, which gives rise to a very fetid, 
abundant discharge. This is known as ozevna syphilitica — a 
form of ulceration so disgusting and offensive as to render 
the subject of it a burden to himself and a curse to those 
who are brought in contact with him. If conjoined with 
necrosis of the nasal bones, the latter are stripped of their 
periostcum and crumble away, causing collapse of the bridge 
and sides of the nose, materially altering the appearance of 
the face. This stage of the disease is frequently associated 
with gummata elsewhere, either of the skin or mucous 
membranes. 

The pharynx, the arches of the palate, the velum palati, 
and the mucous membrane of the hard palate are, during the 
early period of syphilis, the seat of mucous patclies, as well 
as of an erythema coincident with a similar affection of the 
skin. Besides these symptoms later on in the disease, 
u.lcerations, at first superficial, afterward deep, occur, which 
are serious according to "their extent and depth ; but the 
most important lesion which can attack these regions is a 
gummatous infiltration. This is grave in a twofold sense : 
first, from the impediment to respiration which the swelling 



88 VENEREAL DISEASES. 

gives rise to, and secondly, from the after-effects which 
follow cicatrization of the ulcer. The first sign of this 
trouble is a feeling of fulness in the throat, with some 
embarrassment in breathing, due to the sometimes enor- 
mous szue I ling of the tissues of the part. This may be 
unilateral or bilateral ; when the latter, the impediment to 
respiration is very marked, and may necessitate a resort to 
tracheotomy to relieve the urgent want of breath. This 
swelling goes on, unless checked by treatment, to ulceration ; 
and the resulting sore is deep, with undermined edges and 
a copious discharge of gummous matter and pus. If the 
velum palati be the seat of the lesion, perforation and abso- 
lute destruction of this septum may result, throwing the oral 
and posterior nasal cavities into one. When ulceration of 
the pharynx is present at the same time, the cicatrization 
which ensues produces a partial stenosis of the upper por- 
tion of the throat. One result sometimes occurs, of which 
I have shown you two examples, and it is this : when the 
soft palate is only partially destroyed, what remains be- 
comes adherent to the posterior pharyngeal wall, producing 
occlusion of the entrance to the posterior uarcs, which 
would be complete but for cribriform openings in the artificial 
septum, through which nasal respiration is imperfectly 
carried on. If the perforation of the velum is linn ted in 
extent, under proper treatment the opening may contract to 
a size only sufficient to admit a very fine probe ; but my 
experience has taught me that very rarely indeed does the 
opening entirely close up. However, under favorable circum- 
stances the hole left behind is so small as not to give rise 
to trouble, nor to allow regurgitation of solids and liquids, 
such as obtains while the opening is large. 

When the trachea and vocal cords are affected, the symp- 
toms which follow are grave and alarming ; phonation above 



SYPHILIS OF SPECIAL ORGANS. 89 

a hoarse whisper is prevented ; the tracheal rings are often 
necrosed and thrown off ; and death from suffocation may 
result from edema and ulceration of the glottis. 

The esophagus is also invaded, usually in connection with 
syphilis of the larynx and trachea, either from an extension 
of the ulceration or else from gummatous infiltration of the 
tube itself. The stricture of the esophagus, which results 
after cicatrization of the syphilitic ulceration, is a very grave 
complication, and frequently leads to a fatal termination 
from exhaustion, due to inanition, as solid food can not be 
taken in sufficient quantity to support life. 

The tongue, as we have already seen, is the seat of 
mucous patches during the early stage of syphilis, and 
these symptoms are often quite obstinate, recurring again 
and again when all other manifestations have apparently 
vanished. From being slight and superficial the mucous 
patches may, during the progress of the disease, become 
painful and ulcerated, due in part to the disease and in part 
to friction against the teeth. In the later stages of syphilis 
the tongue may be attacked with a gummatous infiltration, 
which may be diffuse or circumscribed. In the former 
variety the entire substance of this organ becomes enor- 
mously sivollen and thickened ; the surface is glazed, and 
presents deep and ulcerated fissures ; mastication is inter- 
fered with, and speech rendered indistinct. If the gummata 
are of the circumscribed form, one or more nodules, hard and 
cartilaginous to the touch, are felt deeply embedded in the 
tissue of the organ. These nodules are painless, and do not 
occasion the patient so much inconvenience as when the 
lesion is diffiise. Both types may pursue one of two courses : 
resolution or idceration. If the first, the thickening and 
ulceration gradually subside, the tongue regains its former 
pliancy, mastication and speech are recovered, and the organ 



90 VENEREAL DISEASES. 

shows no trace of its former trouble. When ulceration 
occurs, the discharge is apt to be abundant and ill smelling ; 
the ulcer deep and excavated, surrounded with a thick mar- 
gin of brawny infiltration ; mastication and speech imperfect, 
while the movements of the tongue are materially hindered. 
This ulceration sometimes lasts for months, causes great 
destruction of the organ, and when it finally heals up, leaves 
a puckered, depressed cicatrix which may deprive the tongue 
of its accustomed mobility. 

Passing to the generative organs, we find that the testicles 
are not infrequently attacked by syphilis in both the early 
and late stages. In the early period, the epididymis of one 
or both testes is hard, thickened, and distended to a some- 
times enormous size. This enlargement is not painful, and 
only attracts attention from its weight and from the drag- 
ging sensation it produces upon the spermatic cord, causing 
a feeling of weakness in the back. This form of epididy- 
mitis almost always disappears under proper treatment, and 
does not interfere with the functions of the part. 

This is not the case in the advanced stage ; here a true 
orchitis is found involving the entire organ. The first thing 
to attract the patient's attention is a sensation of weight in 
the part, accompanied by a dragging upon the spermatic 
cord and a pain in the small of the back. Upon examina- 
tion the entire testis is found very much enlarged, hard as a 
stone, and presenting upon its surface raised projections or 
knobs. There is no redness, and, strange to say, no pain ; 
the organ can be very freely handled without exciting any 
uneasiness. This peculiarity is also present in syphilitic 
epididymitis, and in this respect it differs very much from 
the gonorrheal form of this disease, as I shall show you by 
and by. The shape is piriform, with the small end point- 
ing toward the abdominal ring. If the disease pursues a 



SYPHILIS OF SPECIAL ORGANS. 9 1 

favorable course, the hardness and infiltration subside, and 
the organ may return to its former size and usefulness ; but 
too often atrophy results, and the testis all but disappears, 
sometimes being no larger than a good-sized horse-bean. 
Of course, when this happens, it is neither ornamental nor 
useful. 

The other course which the disease may pursue is ulcera- 
tion. One or more of the projections soften, break down, and 
discharge a mixture of pus and the gummous material with 
which you are already familiar. The ulcer differs in no 
respect from broken-down gummata elsewhere, is chronic, 
sometimes lasting for months before it finally heals, and 
when it does, leaves behind it a deep, depressed sear, sur- 
rounded by atrophied tissue, which is not so extensive as 
where the infiltration has been more general. 

Gummatous infiltration may also occur in the ovaries ; and 
the only symptom present is swelling, usually painless, in 
the ovarian region, conjoined perhaps with some symptom 
of syphilis elsewhere. 

The cervix uteri is not infrequently the seat of the initial 
lesion and of mucous patches, and these symptoms we have 
already studied in a previous chapter. But there is one 
point in this connection to which I invite attention : Both 
these lesions may be seated within the cervix, between the 
os internum and externum, showing nothing externally ; a 
slight discharge is present, but no more than is common to 
nine women in ten. Connection with women thus affected 
gives rise, in the male, to an attack of syphilis, and, unless 
care is taken in forming the diagnosis, the error may arise 
of regarding the syphilis of the man as occurring from 
a gonorrhea or leucorrhea in the female. 

This would be a mistake : the disease is contracted from 
the secretion of an initial lesion or of a mucous patch ; in- 



92 VENEREAL DISEASES. 

deed, accept this axiom : Syphilis comes only from syphilis, 
and not from clap or a chancroid. In the advanced stage 
of syphilis the neck and the body of the uterus are at- 
tacked by gummata, which present themselves in the shape 
of diffused or circumscribed thickening of the organ, which 
may follow the usual course of these lesions, viz. : absorp- 
tion, or, as sometimes happens in the cervix, deep and 
obstinate ulceration, resembling in many respects an exten- 
sive chancroid of the part. We also find the same in the 
male, seated upon the penis, to which I have already alluded 
in a previous chapter. This gumma, besides occurring 
upon the mucous membrane of the male genital organ, is 
sometimes found at the junction of the penis with the 
scrotum — the penoscrotal angle — as a hard, diffused, brawny 
swelling, unattended by pain or redness ; this opens externally 
or internally, and according as it does one or the other 
gives rise to certain symptoms. If the opening is external, 
the resulting ulcer is similar to the ulcerating gummata of 
other parts, and heals up, after a longer or shorter time, 
under appropriate treatment. If, on the other hand, the 
urethra is perforated, the gumma discharges itself through 
this canal, and gives rise to the question of gonorrhea with 
a peri-urethral abscess. In the majority of cases you will 
save yourselves from falling into the error of regarding this 
lesion as a clap, by an observance of the following facts : 
In gonorrhea the discharge precedes the swelling, which is 
red and painful ; in syphilis, on the other hand, the dis- 
charge follows the appearance of the enlargement^ never 
precedes it, and the swelling is neither red nor painful. 

Another form of gumma of the male genital occurs, to 
wit : an infiltration into the corpus spongiosum or into the 
corpora cavernosa. This usually comes on in the circum- 
scribed form, and is apparent as a hard nodidc, without 



SYPHILIS OF SPECIAL ORGANS. 93 

redness or pain, deeply embedded in the tissue of the part, 
or it may occasionally present an annular form around the 
entire organ. It generally passes off under treatment, but 
during its continuance it gives rise to much inconvenience 
and to most curious distortion of the part. If only partial, 
it curves the penis during erection to one side or the other, 
according to the location of the gumma, resembling the 
symptom known in gonorrhea as chordee, and it interferes 
with sexual intercourse ; but if it assume the annular form, 
a most remarkable condition of affairs arises. During 
erection the penis, from the crura to the seat of the lesion, 
is turgid, and presents its usual appearance ; beyond that it 
is flaccid and hangs at right angles to the rest of the organ, 
looking like a flail. Of course, for sexual purposes it is 
entirely useless, and but for the name of the thing, the poor 
patient might as well have no penis at all. 

The alimentary canal and the viscera do not escape any 
more than do other portions of the body. During the 
existence of the erythema a form of icterus has been 
described as due to syphilis, which yields to mercury, but 
it is not until the later phases of the disease that these 
organs are attacked by gummata, usually of the circum- 
scribed variety. These lesions have been found in the 
liver, lungs, heart, kidneys, and intestinal tract ; but the most 
interesting of all the syphilitic manifestations of these parts 
is the gumma of the rectum. This begins in the muscular 
and mucous coats of the rectum, and, by its size, may de- 
cidedly diminish the calibre of the tube. The neoplasm 
ulcerates, producing great pain, attended with a discharge 
of purulent and gummous material, tenesmus, diarrhea, 
and bloody stools. Upon healing it leaves behind it a stric- 
ture of the rectum, which is more or less tight, according 
to the depth and extent of the ulceration, and is usually 



94 VENEREAL DISEASES. 

attended with obstinate constipation from the mechanical 
obstruction to defecation. The stricture is extremely obsti- 
nate and rebellious to treatment, owing to its continual irri- 
tation by fecal matter, and necessitates a resort to the use of 
rectal bougies to keep the passage dilated, and even surgical 
interference, such as a division of the stricture, or even in ex- 
treme cases to colotomy, to prevent the rectum from being 
occluded and the patient's life jeopardized. 

This lesion of syphilis also is of interest in its bearing 
upon the chancroid. Perhaps you remember that in the 
chapter upon chancroid I spoke of the stricture of the rec- 
tum resulting from anal chancroids in the female. The 
after-effects differ in no whit from the same disease due to 
syphilis, and may also require subsequent surgical treat- 
ment for its relief. 

Syphilis may also attack the arteries, from the aorta to 
the smallest capillary ; this usually occurs in the later 
stages of the disease, and is characterized by a cellular in- 
filtration of the mucous and muscular coats of the vessels, 
followed by fatty degeneration. If this lesion occurs in the 
aorta, it can give rise to an aneurism, which may possibly 
be detected during life. If in the brain, the dilatation of 
the arteries is almost impossible of discovery during life, 
and the symptoms which this lesion causes are similar to 
those which ensue from compression of the brain from any 
tumor. Treatment in these cases is probably of little avail, 
as no medication can restore the destruction of tissue which 
takes place in consequence of the degeneration. 

In the brain the syphilitic manifestations usually occur 
during the late stages, due either to a gummatous infiltra- 
tion into the substance of the brain, which probably has its 
starting-point from the meninges ; sometimes, also, from 
disease of the arteries, but the most common variety is that 



SYPHILIS OF SPECIAL ORGANS. 95 

due to gummatous periostitis, which is an infiltration of the 
periosteal lining of the inside of the skull or of the perios- 
teum of the sphenoid or ethmoid bones. These, by compres- 
sion, produce disturbances of the nerve centres, which are 
attended with paralysis, of which I shall speak again when 
we come to treat of syphilis of the ?iervous system and of 
bone. 



CHAPTER VII. 

SYPHILIS OF THE NERVOUS SYSTEM 
AND OF BONE. 

Thus far we have studied the syphilitic lesions which 
occur in and upon the body, with the exception of those 
which affect the nervous and osseous systems, and these 
we shall discuss in this chapter. 

It is generally believed that nervous symptoms belong 
exclusively to the late, or so-called tertiary, form of 
syphilis, but this is a mistake ; lesions of the nervous system 
are found during the early period, being sometimes coinci- 
dent with as early a manifestation as erythema, but they 
differ from late nerve syphilis in being evanescent, more 
amenable to treatment, and in not leaving any permanent 
impairment of the health behind. 

One of the most common symptoms of the early stage 
is the hemicrania, or headache confined to one lateral half of 
the head, and to which, when speaking of the syphilides of 
the skin, I called your attention. This headache has one 
peculiarity, especially well marked in the early period of 
syphilis : it only appears at night ; during the daytime the 
patient is free from it, but on the approach of night it com- 
mences, gradually at first, increasing in intensity when the 
patient goes to bed, and remaining until morning, when it 
disappears. It usually affects one lateral half of the head, 
although it may shift its position to the frontal and occip- 
ital portions ; but this is not common. As the syphilis 

96 



SYPHILIS OF NERVOUS SYSTEM AND BONE. 97 

advances this nocturnal character changes ; it no longer 
disappears throughout the day, although it is less severe 
in the forenoon. Some time in the afternoon it begins to 
increase, and at night becomes so intense as to deprive 
the patient of rest and sleep. The more severe and ad- 
vanced the type of the syphilis is, the earlier in the afternoon 
does this pain commence. 

xA.ssociated with this hemicrania are epileptiform seizures 
of a light and transient character, which, so far as the patients 
are concerned, pass unnoticed, for the simple reason that 
the\* are ignorant of the attack. Sometimes an attack 
occurs in public, when, of course, it becomes known, but 
at other times the only thing to excite suspicion toward 
such a manifestation is a bitten tongue or lips or a bruised 
forehead. The fact that the patient finds himself on the 
floor does not appear to attract his attention. He picks 
himself up as though nothing had happened ; indeed, the 
mental faculties after an attack of this kind seem to be 
wonderfully blunted, and the patient for some hours after- 
ward is in a condition of mental hebetude entirely foreign 
to his usual condition. 

As the syphilis advances these attacks become more fre- 
quent and severe, and unless checked by treatment affect 
the patient 's mind, leading to an attack of downright mania, 
or, what is more commonly the case, to melancholia and 
idiocy. But one point is deserving of notice — the rapid 
and beneficial effect that accrues in cases which at first 
look almost hopeless, under a proper and thorough treat- 
ment. 

Associated with these cases of syphilitic epilepsy — al- 
though not necessarily so — are paraplegia and hemiplegia. 
This latter is usually due to compression of the brain by a 
gummatous infiltration of the periosteal lining of the cranial 



98 VENEREAL DISEASES. 

cavity, or from the meninges of the brain itself, and is 
attended with certain symptoms which tend to distinguish 
it from other manifestations not due to syphilis. First and 
foremost of these stands the suddenness with which the 
attack comes on. The patient, to use a slang phrase, is 
"bowled over" without premonition. Occasionally he 
will confess to having suffered for a short time before the 
attack with severe cranial pain, but just as often as not 
there are no antecedent symptoms: the patient becomes 
suddenly paralyzed. The second noteworthy point is that 
very rarely indeed is there any loss of consciousness ; the 
patient retains Ids senses perfectly, has neitlier stertor nor 
coma : he simply finds he can not move certain portions of 
his body. If he be attacked with hemiplegia, one lateral half 
of his body is useless — if with paraplegia, the lower half; 
and this latter form is connected with obstinate constipation 
and with retention of urine, from the inability of the rectum 
and bladder to empty themselves of their contents. Para- 
plegia denotes some affection of the spinal cord, low down, 
as a rule, and due to compression either from the pressure 
of a gumma in the periosteum of the vertebra? or in the 
sheath of the cord itself; while hemiplegia is caused by some 
brain-lesion. 

Age plays a part also in making up your diagnosis ; and 
you will remember that such lesions as we are now consid- 
ering, occurring in an adult say between the ages of twenty 
and forty-five, of course, excluding accidents, should al- 
ways excite a suspicion of syphilis ; for, apart from injuries 
and the pox, these diseases are rare between the ages I 
have given you. 

Let me supply you with a short table of the differential 
signs between syphilitic and nonsyphilitic paralysis : 



SYPHILIS OF NERVOUS SYSTEM AND BONE. 99 

Syphilitic Paralysis. Nonsyphilitic Paralysis. 

Sudden, unattended by premonitory Gradual, and attended by prodro- 
symptoms. mata, except in apoplexy, when 

the 

Consciousness not lost. Patient becomes unconscious. 

Breathing calm, no stertor. Breathing stertorous. 

Pulse regular and natural. Pulse full, bounding, and irregular. 

Most common between the ages of Usual in advanced age. 
twenty and forty-five. 

This tabular form will, I hope, serve to fix these points 
in your mind. 

Syphilis, of all diseases, seems fond of playing curious 
pranks, and the nervous system affords it ample oppor- 
tunities. Besides the varieties of paralysis which we have 
just gone over there are localized forms that attack certain 
muscles or sets of muscles. The most common of these is 
paralysis of the muscles supplied by the third pair of nerves 
— the motores oculorum communes. In this affection the 
eyeball is partially or completely covered by the lid, which 
can not be raised, and the eyeball is incapable of any move- 
ments except those afforded by the external rectus and the 
superior oblique muscles, which you know are supplied by the 
fourth and sixth pairs of nerves. This produces disturbance 
of sight, with diplopia, or double vision, from inability to 
focus the two eyes simultaneously upon the same object. 
It also affects the iris, producing mydriasis, or dilatation of 
the pupil, which is sometimes extreme. 

Next in frequency come the affections of the fifth and 
seventh pairs, and here we find a complete distortion of the 
muscles of the face supplied by these nerves : the face is pulled 
over to the nonparalyzed side, because there are no antag- 
onistic muscles in action to keep the features straight. The 
tongue, when protruded, is dragged over in the same man- 
ner. The patient can not inflate his cheeks, nor can he 



IOO VENEREAL DISEASES. 

masticate his food, as the buccinator and masseter muscles 
are both incapacitated ; his food collects, during eating, 
between his cheeks and jaws, and can not be dislodged 
save with his fingers, and the saliva dribbles out of the 
corners of his mouth. He presents, in short, a ridiculous 
and at the same time a pitiable appearance. Besides this, 
he can not close the eyelid of the affected side, and as for 
winking with it, that is out of the question ; ( the ala nasi of 
that side does not expand in respiration ; he can not wrinkle 
the skin of his forehead, nor can he frown but with one-half 
of his face, and he may also be made deaf on the diseased 
side. Yet with all this trouble, if the fifth pair be not attacked, 
there is no loss of sensation, for the seventh, as you know, 
is the motor, while the fifth is the sensory, nerve of the 
face. Whether all or only some of these symptoms occur 
depends upon the site of the lesion : if it be anterior 
to the emergence of the nerve, through the stylomastoid 
foramen, all are present ; if posterior, then only those mus- 
cles supplied by the diseased portmis of the nerve are 
affected. 

If the fourth pair is attacked, then the obliquus superior is 
the only muscle at fault, and the patient can not turn the 
eyeball upward and outward, and if the sixth pair is injured, 
the eye can not be everted. 

It is so rare to find these forms of localized paralysis 
apart from syphilis that I do not believe you will ever be 
far wrong in ascribing such lesions to this disease ; and in 
cases where no history can be obtained, the importance of 
a knowledge of this fact will be at once apparent to you. 

Let me, then, formulate this into an axiom for you : 

Paralyses of single muscles, or sets of muscles, are nine 
times in ten syphilitic. 

These affections of the nerves are nearly always unilat- 



SYPHILIS OF NERVOUS SYSTEM AND BONE. 10 1 

eral, and I do not know that they occur more frequently 
upon one side than the other. 

Among the spinal nerves, the one most commonly at- 
tacked is the great sciatic, which springs from the sacral 
plexus. The principal symptom present is pain along the 
course of the nerve, and this pain is not acute, but dull and 
persistent, and is liable to exacerbations at niglit. None of 
the ordinary remedies used for sciatica do more than miti- 
gate the severity of the pain ; but if the surgeon gets upon 
the right track and prescribes the iodid of potassium, either 
alone or, better still, combined with mercury, the result is 
oftentimes as rapid as it is gratifying : the pain vanishes 
as if by magic. 

The lesion which occurs in this variety of nervous syphilis 
is due either to a deposit of gummatous material within the 
nerve sheath itself, to pressure upon the nerve during its 
passage through some bony canal or foramen, by gum- 
mata of the bone, or else to pressure upon the brain or nerve 
substance by a gummatous periostitis. The prognosis de- 
pends much upon the duration of the disease : if the syphilis 
be young, — i. e., in its early stage, — it is favorable ; if the 
contrary, the prognosis is doubtftd, although even here hope 
should not be abandoned ; but if atrophy of the nerve has 
resulted from pressure of the gumma, then good-by to all 
chance of recovery. 

As regards the bones, the lesions here are divisible into 
those which occur during the early and those which occur 
during the late stages. To the former belong the osteocopic 
pains, which produce no organic changes in the bones them- 
selves nor in their investing sheath, the periosteum, which 
are nocturnal in their character, and are at the worst merely 
annoying. As the syphilis progresses these pains lose a 
great deal of their nocturnal character ; they are more per- 



102 VENEREAL DISEASES. 

sistent, but still, with all this, they are not dangerous. These 
pains are usually confined to the shafts of the long bones, 
particularly those which are just beneath the skin, such as 
the tibia and the ulna ; although they sometimes affect the 
flat bones — as, for example, the cranial 

It is when the gummatous stage arrives that trouble of a 
serious nature arises. The first stage is where intense local- 
ized pain occurs in some bone, either flat or long, it makes 
no difference, which is speedily followed by a sivelling at 
this spot, oftentimes exquisitely tender, but usually without 
any redness of the part. This sivelling, if checked at the 
outset, disappears slowly, nearly always leaving some eleva- 
tion and thickening of the periosteum behind it. If left to 
itself or uncontrolled by treatment, the swelling increases 
in size and extent, gradually softens, and opens in one or 
more places to give exit to pus and the gummous material 
which is common to all the lesions of the late stage. If 
this opening be probed, dead bone is almost always found at 
the bottom, and this bone imparts to the touch a sensation of 
irregularity on the surface as though it were worm-eaten. 
And here let me impress upon your minds one very im- 
portant maxim : Never, never under any circumstances, 
open a gummous enlargement of bone or gland, no matter 
how soft it gets ! I have seen gummous infiltrations of this 
kind become absorbed even when the skin covering them 
was as thin as fine tissue-paper and they looked as though 
they must break down. I say to you again, never open a 
gumma, for by so doing you deprive yourself of the only 
chance of preventing necrosis of the bone ; and if this must 
supervene, do not give it a helping hand by stupid interfer- 
ence on your part. 

But we will suppose necrosis already present ; what 
happens then ? The tumor keeps on discharging, and in 



SYPHILIS OF NERVOUS SYSTEM AND BONE. IO3 

the discharge fragments of crumbling bone are found. 
Let me say that the extent of the necrosis is usually confined 
to the size of the periosteal swelling, so that when death of 
the bone has once set in, you can have some idea of its 
limit. The bone crumbles away little by little, presenting 
nothing w. the shape of a firm sequestrum for you to extract ; 
indeed, it seldom has the line of separation from sound 
bone which dead bone of nonsyphilitic origin shows, 
but it simply chips off in small flakes and pieces until it 
has reached the limits of the diseased portion, when, if 
treatment has been properly pursued, the necrosis stops, 
granulations spring up from the bottom and sides of the 
cavity, cicatrization takes place, and a more or less depressed 
cicatrix is left behind to mark the loss of bone. 

When this necrosis occurs in the external osseous frame- 
work, the results, although bad, are seldom serious ; but 
when it occurs in the internal bones, such as the palatine, 
nasal and hyoid, or in the rings of the trachea, — for carti- 
lage disappears as well as bone, — then serious mischief fol- 
lows, not confined alone to the shocking disfigurement 
which occurs, but it may even endanger the patient's life. 
The same proce'ss is repeated here as in the long bones ; 
the gummous deposit takes place into and beneath the peri- 
osteum, stripping the latter from the bone ; necrosis and ex- 
foliation of the bone follow, and when these occur in the 
palatine and nasal bones, the oral and .nasal cavities are 
thrown into one, and the disease may go so far as to attack 
the base of the skull, causing coma, low delirium, and death. 
These are the cases so frequently associated with syphilitic 
cachexia ; and when that stage is reached, hope is about at an 
end. You may perhaps recall such a case which I showed 
you a short time ago, where the hard and the soft palate 
had both disappeared, the nasal bones had 



104 VENEREAL DISEASES. 

the nose to flatten out upon the face ; where necrosis of 
the vertebrae at the posterior pharyngeal wall was present, 
and a sinus led from the inferior orbital angle to a mass 
of dead bone in the lower plate of the orbit. I called 
your attention to the condition of the man, and to his 
worn-out, more-dead-than-alive look, and told you then his 
race was nearly run. He died a week later, in spite of 
treatment, gradually sinking into a low form of delirium 
until death released him from his sufferings. 

These are the cases, happily rare, which once in a while 
present themselves as if to show what syphilis is capable 
of doing, and there is one more form about which I wish 
to speak to you before closing this chapter. This is where 
syphilis attacks the rings of the trachea, and where, from 
pressure of the gumma upon the glottis and trachea, death 
by suffocation threatens to supervene, rendering tracheotomy 
necessary to save life. Under active and persistent treat- 
ment the neoplasm may disappear, but too often the carti- 
lage exfoliates, the rings disappear, and upon cicatrization a 
partial stenosis of the trachea occurs ; and this impediment 
to respiration, combined with the exhaustion so often found 
in these cases, rarely fails sooner or later to end the patient 's 
life. 

The tendons also participate in this disease, and are usually 
attacked in the late stages by a gummous deposit in their 
sheaths. While this lasts it may produce curious deformi- 
ties : as, for example, when it occurs in the tendo Achillis, 
it produces a talipes equinus, and if in the tendons of the 
flexor communis digitorum, it imparts to the hand a peculiar 
claw-like look. Of course, such a hand is useless. 

The symptoms are those of gummata elsewhere : swell- 
ing and thickening of the parts, unattended by much pain. 
They usually yield to treatment, but sometimes permanent 



SYPHILIS OF NERVOUS SYSTEM AND BONE. IO5 

contraction ensues, rendering tenotomy necessary in order 
to restore the parts to some degree of usefulness. 

We have now gone over the principal points in the history 
and course of syphilis, and I trust that the pictures I have 
sketched for you in these chapters will enable you to recog- 
nize all the cases which you will be likely to see in every- 
day practice. The next chapter will be devoted to the 
treatment of syphilis — a very interesting subject, and to the 
importance of which I think you are keenly alive. 



CHAPTER VIII. 

TREATMENT OF SYPHILIS. 

As regards the treatment of syphilis, allow me to say at 
the outset that to discuss, pro or con., the various methods 
which have been in vogue since syphilis has been recog- 
nized as a separate disease would not come within the 
scope of this book ; and what I therefore propose is to 
give you the kind of treatment which has best stood the 
test of time, and which, at the present day, is the most ap- 
proved. With this object in view I shall divide my topic 
into the two principal groups of internal and external treat- 
ment, and give you, as I go along, the appropriate prescrip- 
tions for each. 

In the first place, as regards the treatment of the initial 
lesion. I have already, when previously speaking of this 
form of syphilis, given you the plan most deserving of 
adoption, and will therefore do no more than refresh your 
memory upon some of the principal points to which I then 
called your attention. 

In the first place, do not cauterize the initial lesion unless 
it be attacked by phagedena, when such a proceeding may be 
admissible ; but when it is uncomplicated, cauterizing does no 
good ; on the contrary, it does harm. In the second place, 
do not treat it by the internal use of mercury, for the reason 
that this metal retards the appearance of the early syphilides, 
and leaves the surgeon in doubt when to expect subse- 
quent lesions and what to look for, and also because its 
use sometimes prevents the surgeon from deciding with 

1 06 



TREATMENT OF SYPHILIS. 107 

certainty upon the nature of doubtful ulcers ; and when, 
the period of probation passing by and no symptoms 
appearing, he assures his patient that nothing further is to 
be expected, his promises of future indemnity are apt to 
be rudely dispelled by the appearance of the long-delayed 
syphilides some months later. In addition to this, waiting 
until the syphilides appear does not injure the patient's 
chances of ultimate recovery. Treat the initial lesion, then, 
by the rules laid down in chapter in. 

When the syphilides appear, however, and the time for 
internal medication arrives, what shall we do ? In the 
early stages of syphilis, you remember, the symptoms are 
multiple and polymorphous, and when the six weeks of 
incubation have elapsed, your patient blazes out with an 
erythema of skin and mucous membranes, papules in the 
scalp, mucous patches of the tongue and throat, alopecia, 
hemicrania, and universal induration of the glands of the 
body. Preceding these symptoms there probably has been 
some febrile excitement, which disappears as the eruption 
shows itself. Now is the time for the use of mercury ; and 
let me tell you that, of all the drugs at your command for 
the treatment of syphilis, there is not one that will take its 
place. Dismiss from your minds the senseless abuse of 
mercury which some writers indulge in, and remember that 
the surgeon who neglects to use this mineral in treating 
syphilis does injustice both, to his patient and to himself; for 
although some mild cases of syphilis may and do recover 
without its use, the risk run is greater than any prudent 
surgeon should incur. Know what to expect from your 
drug, use it properly, and depend upon it that those two 
points well carried out, the mercury will do no harm either 
in the present or the future ; on the contrary, it will do 
good. 



108 VENEREAL DISEASES. 

In the early stages of syphilis — i. e., through the period 
of erythemata and papulae — a preparation I frequently use 
is the following : 

R. Mass. hydrargyri, gr. ij 

Ferri sulphatis exsiccat., gr. j. 

Fiat pil. No. i. 

M. 

Sig. — Three to six daily. 

I usually begin with one three times daily after meals, 
gradually increasing the number to two three times daily 
as occasion requires. 

The bichlorid of mercury is the old and time-honored 
preparation which has been usually given. I very seldom 
use it, because in my hands it has been apt to produce its 
toxical qualities — griping of the bowels, diarrhea, and spon- 
giness of the gums — -just when it is most needed. Still, in 
some cases it answers well enough, and when used, it had 
better be given in pill form, thus : 

R . Hydrargyri bichloridi, gr. g^-io 

Saponis, q. s. 

Ut flat pil. No. i. 

SiG. — One thrice daily after meals. 

In order to check its action upon the bowels, from \ to 
i grain of opium may be added to each pill. 
Another form is the protiodid of mercury pill : 

R. Hydrargyri protiodid., gr. \— \ 

Ext. gentianse, q. s. 

Ut fiat pil. No. i. 

SiG. — One thrice daily after meals. 

But of all these preparations of mercury, as already 
stated I much prefer the one first given, the blue mass and 



TREATMENT OF SYPHILIS. IO9 

iron pill, for its efficacy and for the tolerance which the sys- 
tem shows to it. The addition of the iron is of value not 
only in increasing the action of the mercury, but for its own 
effect as a tonic. 

Now come the questions : how long shall the mercury 
be continued? how much shall be given? and under what 
circumstances shall it be increased, diminished, or stopped 
altogether ? To the first two questions I reply, until the 
symptoms disappear or the drug produces toxical symptoms ; 
by that I mean disturbance of the digestion, diarrhea, 
sponginess of the gums, and salivation. With regard to 
this last point, I wish to impress upon your minds the fact 
that its occurrence is a hindrance, not a benefit, to treatment, 
inasmuch as, when present, the mercurial has to be stopped 
and so much time wasted. Avoid then, carefully, any 
approach to salivation ; but should such an accident occur, 
suspend all anti syphilitic treatment and place your patient 
upon the following prescription : 

R. Potassse chlorat., £j 

Aquae, ^ v j« 

M. 

Sig. — Locally as a mouth- wash, and internally in teaspoonful doses 
four or five times daily. 

This checks the sponginess of the gums, the fetor of the 
breath, and the flow of the saliva, which are the three 
symptoms attending this form of mercurial intoxication. 

Two other remedies have been used, both of which may 
be of service. They are belladonna, or its alkaloid, atropin, 
and dilute nitric acid. They are usually given as follows : 

R . Tinct. belladonnse, % iv 

A q u3e > |ij- 

M. 

SlG. — Teaspoonful four times daily in water. 



110 VENEREAL DISEASES. 

If you use atropin instead of belladonna, give the fol- 
lowing : 

R. Atropine sulph., S r - rV 

Alcoholis, ^ss 

Aquae, q. s. ad ^ ij. 

M. 

Sig. — Teaspoonful three or four times daily. 

With preparations of belladonna use the solution of the 
chlorate of potash given above as a wash. The dilute 
nitric acid you will oftentimes find of benefit in those cases 
where the sponginess of the gums is so excessive as to 
threaten the dropping-out of the teeth, and should be 
given both internally and locally : 

J&. Acid. nit. dil., ^iv 

A q u£e > lij. 

M. 

Sic — Teaspoonful four times daily in water ; also use locally. 

If, however, you give mercury prudently and properly \ care- 
fully watching your patient, no such accident as I have just 
detailed need occur ; and, indeed, you will oftentimes be 
surprised to see how tolerant the system is in syphilis of 
even large doses of this mineral. I have often given in 
these early stages of the disease ten to twelve, and even 
fourteen, grains of blue mass a day for several weeks at a 
time without producing any systemic disturbance whatever ; 
but it Avas in those cases where the attack was severe, and 
I was careful to keep the patient under rigid observation. 
In average cases six to eight grains daily will be sufficient 
to dispel the symptoms. 

As to the circumstances which shall impel us to increase, 
diminish, or altogether stop the mercurial, they may be dis- 
posed of in a few words. If the symptoms be obstinate and 
slow to disappear, and if, at the same time, the patient 



TREATMENT OF SYPHILIS. Ill 

stands his treatment well, the drug may be gradually in- 
creased until the symptoms give way or the patient begins to 
show a slight red Hue at the edges of the gums. Should 
this latter occur before the disappearance of the syphilitic 
lesions, the mercury must be suspended for a few days, and 
when it is recommenced, a different preparation may be 
given from the one formerly used. It is seldom, however, 
that the earlier manifestations resist a determined attack with 
this mineral. 

As soon as the symptoms have disappeared so as to leave 
no staining of the skin or other trace of their presence 
behind them,, it is well to discontinue the use of the mercurial, 
for the following reasons : first, to avoid too great a toler- 
ance of the system to the drug ; and, secondly, to enable 
us to determine whether other lesions are about to follow or not. 
Upon this last point let me dilate a little, even at the risk of 
seeming tedious, in order to avoid misunderstanding upon 
your part. We will take, for example, one of the many 
cases which I have already shown you from the wards — 
say this one, of a papular syphilide. As soon as the 
manifestations have disappeared from the skin, leaving no 
trace behind them, the mercurial treatment will be discon- 
tinued and the man placed upon tonics. Now, if you will 
remember what I have told you when we were speaking of 
the syphilides of the skin, you will recollect that there is a 
period of incubation, shorter or longer as the case may be, 
between the appearance of the various manifestations, and 
if you continue your treatment after the first train of symp- 
toms has disappeared, you delay the occurrence of the 
subsequent ones. But suppose you intermit your treatment 
instead of continuing it, and the period of probation passes 
without the expected symptoms appearing — this shows 
you that the disease is losing its strength (for the amount 



112 VENEREAL DISEASES. 

of mercury you have already given for previous symptoms 
would not prevent the subsequent manifestations if the 
syphilis were still very active), and you would be justified 
in supposing that the disease was on the wane, and the 
longer the time which elapses between the various stages, 
the more hopeful the prognosis. But bear in mind that as 
long as any symptoms last, no matter how slight, so long 
must the treatment be continued ; and also that it must be re- 
newed, if previously discontinued, should fresh manifestations 
recur. 

This touches upon internal treatment only ; but occa- 
sionally some lesions require a topical as well as a constitu- 
tional medication. Of these, mucous patches head the list. 
The early lesions of the skin, of course, require no local 
applications ; it is only where the erythematous blotches 
and papules invade skin and mucous membrane together — 
as, for example, at the angles of the mouth and eyelids, or 
in other portions of the body which combine heat and 
moisture, such as the pourtour of the anus, the labia vulvae, 
the scrotum and penis, the toes, the buttocks, and armpits 
— that topical treatment becomes requisite. The two best 
remedies for these lesions are powdered calomel and the 
application of the nitrate of silver either in the solid stick 
or as a saturated solution. But do not forget the most 
important point of all : keep the parts dry and clean, else 
your treatment will be of little avail. 

This question of cleanliness is particularly important if 
the mucous patches are seated upon the lips or tongue or 
in the throat, as a nonobservance of this rule tends not only 
to the continuance of the mucous patches, but also to their 
increase in both size and intensity. Hence it is well to advise 
the patient to brush the teeth several times during the day, 
and to gargle and rinse the mouth with warm water to which 



TREATMENT OF SYPHILIS. I I 3 

some mild antiseptic, such as listerine or borolyptol, may 
be added. 

When the mucous patches are seated in the throat, or on 
the lips, tongue, and lining membrane of the cheeks, the appli- 
cation of the nitrate of silver is generally the most efficacious ; 
and when the lesions are seated low down in the pharynx, a 
spray of a weak solution of nitrate of silver (five grains to 
one ounce of water) will be of advantage. 

As the later stages of the disease are reached the treat- 
ment undergoes certain modifications ; the one best calcu- 
lated to promote a cure is that known as the mixed treatment. 
This consists of mercury and the iodid of potassium, used 
either separately or in combination, and is given in those 
stages of the disease which are ulcerative in their character. 
I much prefer giving the two separately, for facility of exhibi- 
tion and because either one can be increased without increas- 
ing the other. The two preparations of mercury most in 
use are the protiodid (internally) and the ordinary mercurial 
ointment, or oleate of mercury, as an inunction to the skin. 
If the internal use of the drug be decided upon, the prot- 
iodid should be given once daily, in from a half to one grain, 
and the iodid of potassium in two daily doses, thus : 

R . Plydrarg. protiod. , gr. ss-j 

Ext. gentianae, , q. s. 

Ut fiat pil. No. i. 

Sig. — Once daily before mid-day meal. 



And— 



R . Kali iodidi, g ij 

Tinct. cinchonae comp., 

Tinct. gentianae, aa ^ ss 

Aquas, q. s. ad 3 ij. 

M. 

SlG. — Teaspoonful well diluted with water twice daily — morning and 

evening — before meals. 
IO 



114 VENEREAL DISEASES. 

A very good way of giving the iodid is to make it up in 
a saturated solution, and, as the iodid is very soluble in 
water, an aqueous solution will represent very nearly a 
grain of the salt to each minim of the solution, and by 
giving it in this saturated form, the amount of iodid may 
be increased or diminished at will, without making each 
dose too bulky when large amounts of the salt are to be 
given. It is well to remember, however, that the iodid must 
be well diluted with water, milk, or with some mineral water, 
such as Vichy or the carbonated waters, first, because it is 
easier of absorption, and, second, because it has less tendency 
to irritate or disturb the stomach if given largely diluted. 

Should you elect to combine the mercurial and the iodid 
of potassium in. one dose, you will find the following pre- 
scription a good one : 

R. Hydrarg. bichlor., . . . gr. }(-]. 

Or— 

R. Hydrarg. biniodidi, gr. }(-} 

Kali iodidi, • !jij 

Tinct. gentianae, 

Aquae, aa ^j. 

M. 

SiG. — Teaspoonful well diluted with water twice daily — morning and 
evening — before meals. 

If possible, these medicines should be given before eating, 
as the absorption is quicker and the effect more direct when 
the drugs are given on an empty stomach ; but sometimes 
you will have to modify this rule and give the remedies 
after eating, because both the mercury and the iodid of 
potassium sometimes produce stomachic and intestinal dis- 
turbances if given upon an empty stomach. 

But we will suppose you do not wish to give mercury in- 
ternally by the mouth, but prefer some other mode of ad- 



TREATMENT OF SYPHILIS. I I 5 

ministration. What methods are open to you ? There 
are three : first, by inunction — /'. e., friction on the skin — of 
some oleaginous or fatty preparation containing mercury ; 
second, by mercurial vapor baths ; and third, by subcutane- 
ous injections. 

The first of these methods, by inunction, although a most 
excellent way of getting a rapid and at the same time 
thorough effect of mercury, is open to the serious objection of 
uucleauiiness, and with justice, as the old-fashioned way of 
smearing the ointment over the entire body in divided 
doses kept the body and linen in a constant state of greasi- 
ness and dirt. This, in recent times, has been much im- 
proved upon by the use of the oleate of mercury ; but which, 
though better than the unguentum hydrargyri of the phar- 
macopoeia, is repugnant to many persons who are careful 
about the cleanliness of their persons. To obviate this, 
and to reduce the dirty feeling which any greasy substances 
impart to the skin, I have for some time past used the oleate 
of mercury \ 10 per cent, to 20 per cent, strength) on the soles 
of the feet to the exclusion of the ordinary mercurial oint- 
ment, in the following manner : 

The patient is directed to bathe the feet thoroughly in 
hot water the night on which the first inunction is made, 
when half a drachm of the 20 per cent, oleate of mercury 
is rubbed briskly into the sole of the right foot ; this is 
repeated the next night on the left foot, and so each night, 
the right or left foot alternately is anointed with half a drachm 
of the preparation. This may be increased to a drachm or 
more if the patient stands the mercurial well. The same 
stockings, which should be of wool or some tolerably 
thick material, are worn continuously, night and day, for 
one week, at the expiration of which time the feet may be 
thoroughly cleansed with hot water and soap, and an in- 



I I 6 VENEREAL DISEASES. 

termission of three or four days elapse before renewing this 
same process for a similar length of time. The iodid of 
potassium should be kept up during the period of inunction 
as well as during the intermission, in three daily doses. 

The advantage of this method is twofold : first, as 
regards cleanliness ; second, as to efficacy. Instead of 
smearing the body all over and keeping it continually in 
a dirty state, this disagreeable feature of the treatment is 
confined to the feet, and the repeated dose is in a process of 
continual absorption, inasmuch as every movement that the 
patient makes in walking serves to nib the ointment into the 
skin of the feet, and absorption takes place notwithstand- 
ing the thickness of the cuticle in this part. 

The second method, by the vapor bath, is equally effica- 
cious, and not open to the same objections that the inunction 
process is. The patient may be sent to one of the regular 
establishments where these baths are given, or, if preferred, 
they may be given in the patient's own house. The portable 
vapor bath in its simplest form consists of a long, sleeve- 
less flannel night-shirt, made to reach to the patient's 
feet, an india-rubber mackintosh of the same pattern 
as the flannel shirt, both of which should close tightly 
round the neck, leaving the head exposed, and a round 
stool for the patient to sit upon. The flannel shirt and the 
mackintosh should be made large enough to allow the 
patient to sit upon the stool inside of both. The vapor 
bath is a cvlinder of tin or of wire «- a uze, enclosing; within 
it an alcohol lamp. The upper portion of the cylinder 
holds a plate, which is hollowed out in the shape of a 
gutter at its outer circumference ; the middle portion is 
elevated above this gutter, and contains a shallow depres- 
sion or cup. The patient, being stripped and dressed in 
his shirt and mackintosh, is seated upon the stool, which is 



TREATMENT OF SYPHILIS. \\J 

included within his bath clothing, and the whole is care- 
fully tucked in at the bottom, to prevent the escape of any 
vapor. The bath is prepared in the following manner : 
water is poured into the gutter of the plate at the upper 
portion of the cylinder, and the mercurial is placed on the 
shallow cup at the apex, in the middle ; the lamp is then 
lighted, and the whole apparatus placed under the stool 
upon which the patient is sitting. The lamp is so ar- 
ranged that the flame striking against the plate at the top 
causes evaporation of the water, producing a steam vapor 
bath, and the heat throws the patient into a profuse per- 
spiration. As soon as the water has evaporated the mer- 
cury, in its turn, is volatilized and readily absorbed by the 
skin. As soon as all the mercury has disappeared the light 
is put out, and the patient is left inside his waterproof 
clothing until the body begins to cool slightly ; he should 
then be taken from his stool, the waterproof cloak re- 
moved while the flannel shirt is retained, and he should be 
covered up with blankets until all perspiration has ceased 
and the body has become cool and tolerably dry, when he 
may put his clothes on again. This is supposing the bath 
to be given in the day, but bedtime is the best period of 
administration, when the patient may go to bed at once 
and remain there. 

A good substitute for the lamp is an ordinary chafing-dish, 
the tin or zinc plate of which may be replaced by an iron 
saucer to contain the water, which, upon evaporation of 
the water, becomes thoroughly heated. When this is 
accomplished the mercury may be placed upon the still 
hot plate, producing the same result which is attained by 
the regular apparatus. 

An improved modification of the above apparatus is the 
cabinet vapor bath, of which several varieties are on the 



I I 8 VENEREAL DISEASES. 

market. The modification consists in substituting a more 
or less air-tight box for the flannel night -shirt ; otherwise 
the two instruments are similar. The principle is the 
same in both. 

The preparation of mercury used is either calomel or 
the black oxid, the former being given in twenty to forty 
grains to each bath, and the latter in thirty to sixty. 

The time required for the bath varies from' thirty to forty 
minutes, and, barring the length of time it takes, is one of 
the nicest and cleanest ways of introducing mercury into 
the system, besides being of easy application. 

The method by subcutaneous injection is very little used 
in private practice, owing to the trouble of administration 
and the pain attendant upon it. It is done by injecting 
the solution containing mercury beneath the skin, which, 
besides being painful, is frequently followed by abscesses at 
the point of injection. Calomel is the agent usually se- 
lected, and is given in doses varying from T ^ to \ a grain 
at each injection. 

The local treatment of the ulcerative syphilides, although 
not so important as the constitutional treatment, is decidedly 
necessary and useful. Those of the skin, if the crust has 
been removed, should be dressed with mercurial ointment 
spread upon a cloth. It is better, however, to leave the crust 
on, if it be firmly adherent, as it makes the best protection for 
the part, and the underlying ulcer heals up under the ad- 
ministration of the mercury and iodid of potassium. The 
ulcerations occurring in the throat and mouth should be 
treated with nitrate of silver (40 grains to one fluidounce of 
water), carbolic acid (crystals, one or two grains to one 
ounce of water), or nitric acid (nitric acid, c. p., five minims 
to one ounce of water). If the lesions are deeply seated in 
the throat or in the posterior nasal cavity, they may be 
reached by a spray of the above solutions. 



TREATMENT OF SYPHILIS. II9 

In necrosis of the nasal and palatine bones the parts should 
be thoroughly washed out with warm water, injected through 
a posterior nasal syringe, and afterward sprayed with the 
solutions given above, and patience exercised until the dead 
bone comes aivay under internal treatnie?it. - 

I now wish to say a few words to you with regard to the 
administration of your remedies, because upon the tlwrough- 
ness with which you use them will the advantage of your 
treatment largely depend. Without at all advising you to 
be rash, I wish you to be bold, and to remember that in face 
of such a disease as syphilis you can not afford to trifle. 
When using mercury, watch your patient carefully, be on 
the lookout for toxical symptoms, but do not hesitate, if occa- 
sion requires, to push your medicines to the utmost limit 
which the patient will tolerate. I believe more harm is done 
than is generally known, in many cases, because the sur- 
geon is afraid to use mercury in sufficient quantities to 
control the disease, and in syphilis, you must recollect, mer- 
cury, instead of acting as a depressant, seems to possess the 
properties of a tonic — indeed, it is the sheet-anchor in treat- 
ment. The same is true of the iodid of potassium, so far as 
regards its tonic property : of little, if any, value in the earlier 
stages of syphilis, in the later (jdcerative) periods it is invalu- 
able, but only as an adjuvant ; it never will take the place cf 
mercury. Give it at the commencement in ten -grain doses, 
gradually increasing the amount until the symptoms are 
controlled or iodism occurs. This is cliaracterizcd by coryza, 
lachrymation, and an eruption of papules and pustules on the 
face and shoulders (acne), and occasionally, though very 
rarely, by blebs. As to the quantity, it may perhaps surprise 
you to hear how much of this salt patients w r ith advanced 
syphilis will stand ; it is sometimes enormous. For exam- 
ple, in the case of Quinn, the patient I showed you with 



120 VENEREAL DISEASES. 

nervous syphilis, in whom the symptoms were distortion of 
the face and paralysis of the leg and arm of one side, at- 
tended with severe pain in the head and insomnia, the 
amount given was 120 grains at each dose, and this was 
repeated three times daily. In addition to this he used a 
drachm of mercurial ointment every night by inunction, and 
perhaps you remember that when, after ten days of such 
treatment, I presented him to you again, the facial paralysis 
had almost entirely disappeared, the arm and leg had re- 
gained a great deal of their power, and he had lost much of 
the cachectic appearance which he formerly showed. And 
yet the case at first looked anything but promising, and it 
only shows the importance in these advanced cases of large 
doses of the salt. Large as the above amount is, it is not 
so great as I have sometimes used, and I will formulate 
here some axioms which may be of use for you to remem- 
ber in the treatment of syphilis : 

Mercury is the main-stay in treatment, not only in the 
earlier, but in the later stages as well. 

Iodid of potassium is of little service in the earlier stages ; 
in the later stages, although of extreme value, it only assists 
in dispelling symptoms ; to produce radical effects it should be 
combined cvith mercury. 

111 giving both mercury and iodid of potassium watch your 
patient carefully t to obviate the occurrence of toxical symp- 
toms, but do not hesitate to use either remedy in sufficient 
amount to dispel the symptoms, no matter what the requisite 
dose may be. 

You will oftentimes find in the graver forms of the dis- 
ease, such as gummata or nerve syphilis, that doses of 
twenty or thirty grains produce little effect ; carry your dose 
up to fifty or sixty grains, and you will have the gratifica- 
tion of seeing your patient improve at once. What the mode 



TREATMENT OF SYPHILIS. 121 

of action is I can not tell, for curiously enough, when 
given in large doses, nearly all the iodic! of potassium 
used can be collected in the urine ; thus, if a dose of sixty 
grains be given, forty of it will be excreted, leaving twenty 
to be absorbed, and yet if you give only twenty grains 
instead of sixty, it makes no sort of impression on the 
disease. 

It sometimes, though rarely, happens that the patient, 
through some idiosyncrasy, can not tolerate iodid of potas- 
sium ; in those cases the simple tincture of iodin may be 
used as a good substitute. It should be given in the fol- 
lowing prescription : 

]£. Tinct. iodi, ^ss 

Syr. fusci vel syr. aurant. , ad 3 iv. 

M. 

Sic — One teaspoonful well diluted with water three times daily before 
meals. 

This preparation is usually well borne by the stomach 
and is by no means unpalatable. 

The amount of this should also be increased precisely in 
the same way as the iodid of potassium, although the 
amount required will probably not be as large. 

When we were discussing the natural history a?H symp- 
toms of syphilis, I spoke to you about what is known as 
syphilitic cachexia, a condition characterized by lardaceous 
changes in the viscera. This is a very grave and serious 
complication, because the system refuses absolutely to 
absorb either food or medicine. When this occurs, the 
treatment by mercury and iodid of potassium, if continued, has 
to be combined with tonics and stimulants, which should be 
given with a liberal hand. Of the tonics, the principal 
ones are the ferruginous preparations, either alone or com- 
bined with cod-liver oil, and among the stimulants, the 



122 VENEREAL DISEASES. 

more diffusible ones, such as champagne and brandy ; but 
when a patient arrives at this stage of the disease there is 
little hope, and all that there is left for the surgeon to do is 
to make the road to the grave as easy as possible. 

As regards the duration of treatment in the later stages, 
it must of necessity be prolonged, as the symptoms are 
more obstinate in character than in the early part of the 
disease. The patient should be prepared to continue his 
treatment for a year, and longer if occasion requires ; and 
this, too, even if all symptoms have disappeared, varying 
in this respect from the treatment given in the early periods 
of the disease. After treatment by antisyphilitic remedies 
has been continued as long as the surgeon deems neces- 
sary, the patient should be subjected to a thorough course of 
tonics, in order to complete what the mercury and iodid of 
potassium have begun. 

Before closing this chapter let me say a few words to you 
in regard to prognosis. In the majority of cases it is good ; 
patients recover entirely from their disease, oftentimes 
without showing any of the serious lesions such as you 
meet with in the wards of hospitals, and examples of which 
I have already shown you. By recovery I mean that patients 
~,tow afi.er the disease has run through a certain course, 
no further symptoms of syphilis, even though they have 
been kept under observation for several years ; and should 
they marry, their offspring show no sign or taint of disease 
so far as syphilis is concerned. It is not in the acquired 
form of syphilis that fatal results occur so much as in the 
hereditary form, where the mortality is large, and where 
even should the child survive to puberty, it is liable 
throughout its whole life to show symptoms of its inherited 
malady. 

If acquired syphilis proves fatal, it is usually so in con- 



TREATMENT OF SYPHILIS. 1 23 

sequence of its indirect attack upon the vital organs of the 
bod\', — to wit, upon the kidneys, the heart, or the lungs, — 
and it is quite possible that many fatal cases of nephritis 
and of pneumonia may have had their starting-points from 
some antecedent syphilis from which the patient had appar- 
ently recovered. It is well to bear this fact in mind, for 
in some obscure cases where no cause for the disease can be 
assigned the use of iodid of potassium may avert what 
would otherwise be a fatal termination in the case. 

In short, you may accept the following- rules as a toler- 
ably good guide in cases of acquired syphilis : 

The average case of syphilis runs its course in from eigh- 
teen to twenty-four months. 

Under proper and careful treatment the graver forms of 
the disease seldom occur. 

After the disease has apparently run its course and anti- 
syphilitic treatment has been suspended, the patients should be 
kept under occasional observation for another eighteen months, 
and if in that time no symptoms make their appearance, they 
may, as a rule, make their minds easy as to the future. This, 
you see, embraces a period of three and a half years, one 
half of which is devoted to the disease, and the other half to 
watching for further developments. 

These rules, you understand, are not absolute ; indeed, 
none such can be given, but I believe they will serve as 
tolerably safe guides for you to follow. 



CHAPTER IX. 

HEREDITARY SYPHILIS AND ITS TREAT- 
MENT. 

We have heretofore discussed only the various phases 
of acquired syphilis. This chapter will be devoted to a 
consideration of the hereditary forms of the disease. 

Hereditary syphilis may be divided into three principal 
groups : the first, where it occurs at or shortly after birth ; 
the second, where it shows itself during childhood or at 
puberty ; and the third group, known under the name of 
"syphilis hereditaria tarda" where the lesions do not occur 
until after puberty and during adult life. It is claimed that 
the earlier lesions of hereditary syphilis have been absent in 
the last group ; but this I believe to be a mistaken view, for 
in these cases of late hereditary syphilis traces are some- 
times discoverable of earlier lesions, and the history will 
oftentimes furnish us a clue as to what has gone before. 
The lesions which occur at this stage are those of the so- 
called tertiary, and arc really gummatous infiltrations, with 
their frequent attendant loss of tissue. There are, how- 
ever, two notable periods of explosion, viz. — at birth and at 
the period of puberty. We will commence with the first 
of these — syphilis at or shortly after birth. 

When the disease show T s itself at birth, the child may be 
either born dead or, if alive, it usually succumbs in the 
course of a few days. The body is covered with large 
bidlce, filled with serum mixed with blood. These bullae 
speedily break, evacuate their contents, and the epidermis 

124 



HEREDITARY SYPHILIS AND ITS TREATMENT. 125 

covering them exfoliates, leaving a red, denuded surface 
beneath. This constitutes what is known as pemphigus 
neonatorum syphiliticum. When the disease in the mother 
is not very far advanced, the child may be born to all appear- 
ances sound and healthy, not developing any signs of the 
disease until some weeks or even months after birth. Of 
course, the longer the symptoms are delayed, the greater are 
the child's chances of viability. 

Syphilis in the infant appears almost always within the 
first six mouths of extra-uterine life ; in the majority of 
cases within the first three. After a time the child loses its 
plump and well-nourished look, becomes thin and querulous, 
refuses the breast, and an eruption of the erythematopapidar 
variety appears upon the body, legs, and arms, particularly 
upon the soles of the feet and the palms of the hands. Con- 
joined with this eruption are mucous patches of the mouth, 
throat, axilla?, and about the anus and genitals. The child 
is afflicted with " snuffles ," a genuine coryza of the nasal 
mucous membrane, which renders respiration difficult. The 
healthy cry of the infant is exchanged for a hoarse, 
stridulous noise, due to the invasion of the larynx by the 
disease, and the child sinks rapidly from exhaustion and 
inanition or from a direct poisoning by the syphilis. An 
autopsy reveals interstitial changes of the internal organs, 
especially in the liver and kings, corresponding with the 
early stages of the gummous period. Not infrequently the 
child, before death, may be attacked by convulsions, due to 
inflammation of the meninges of the brain or spinal cord. 

If the symptoms are not developed until at or near the 
sixth month, they are less formidable in their course, being con- 
fined to manifestations corresponding with the earlier stages 
of acquired syphilis. These consist of the erythematous and 
papulopustular eruptions of the skin, conjoined with the moist 



126 VENEREAL DISEASES. 

secreting lesions of both mucous membrane and skin, which, 
from their delicacy in infants, are peculiarly liable to be 
attacked. Under vigorous treatment the disease gradually 
subsides, and the child passes through the earlier years of 
its life with only occasional outbreaks] until the period of the 
second dentition arrives, when certain changes occur. Before 
that period, however, there are certain peculiarities of physi- 
ognomy which deserve attention. The forehead is very 
prominent and bulging ; the bones of the face appear ab- 
normally small, those of the nose are sunken, and the child 
has a wizened and aged appearance ; the angles of the mouth 
are more or less deeply scarred, and the skin has an un- 
healthy, sallow look, different from the wholesome, clean 
complexion of sound children. 

This description which I have given you is true in so far 
as it concerns the classic type of early hereditary syphilis, but 
you must remember that it is not constant and many a child 
is born into the world which presents no such marked evi- 
dences of its inherited disease, and, should it survive the first 
twelve months of its existence, may grow up with none of 
the stigmata of disease about it ; on the contrary, it may 
seem to be quite healthy : certainly as healthy as the aver- 
age type of children. 

We will suppose now that the child has survived the 
dangers of the earlier months of its syphilitic existence, and 
that the treatment which has been instituted has assisted 
it to overcome the first symptoms of its disease. Let us 
see what other lesions of the skin may befall it in its course 
toward puberty besides the erythematous and papular erup- 
tions of which I have just spoken. 

There is a form of syphilis which has been described — 
and which I am perfectly free to say I have never seen — as 
a syphilitic manifestation, to wit : a vesicular syphilide in 



HEREDITARY SYPHILIS AND ITS TREATMENT. \2J 

which the eruption, beginning perhaps first as papular, be- 
comes vesicular at its apex, and this little vesicle rapidly 
loses its covering, becomes irritated, and secretes a moist, thin 
fluid which dries upon contact with the air. If this be 
removed, the skin underneath it is found to be red, but 
without ulceration, and often occurs in large patches cover- 
ing extensive portions of the skin. Do not forget this one 
fact, that the skin of any child is always thin and tender, 
and especially is this true of a syphilitic one, and the irrita- 
tion of the skin, due perhaps partially to the disease and 
partially to natural causes, tends to produce more or less 
inflammation. I believe that many, if not all, of these cases 
of vesicular syphilis — and I base my opinion upon both per- 
sonal experience and study of the cases of others — are 
nothing more than a vesicular eczema occurring upon a 
syphilitic child. 

Another variety of eruption is one which has been de- 
scribed as syphilis hemorrhagica neonatorum. This, how- 
ever, is only a variety of the pemphigus, which I have already 
described, and is a more malig)iaut type of the same affec- 
tion. It is characterized by the effusion of blood into the 
bidlce, which gives the eruption a reddish or purple appear- 
ance and is usually fatal. 

Subcutaneous phlegmona have also been described as due 
to hereditary syphilis, and one observer has regarded a case 
of gangrene of the forearm as the result of this same 
disease. 

The affections of the nmcous membrane which occur in the 
earlier stages of hereditary syphilis are principally mucous 
patches, which occur in the mucous membrane of the nose, 
the mouth, larynx, and pharynx, and if they occur some 
little while after birth, — say six or nine months after, — they 
are usually curable and the child recovers from them. If 



128 VENEREAL DISEASES. 

they occur earlier and are associated with the more severe 
symptoms, which I have already detailed, the child generally 
dies. There are other lesions which occur later on, but 
which I shall reserve until I come to speak to you of the 
late type of inherited disease. 

The lymphatics and glands are also affected, not only 
those which are superficial, but those which are deep. 
Thus the bronchial and mesenteric glands, the inguinal 
glands, the lumbar glands, the iliac, hypogastric, thoracic, 
axillary, and carotid — in fact all the abdominal and thoracic 
glands may be affected ; but there is one oi all others which 
is most liable to disease, and that is the thymus gland. This 
gland is frequently much enlarged from infiltration of gum- 
matous material, but it is sometimes found of normal size 
and does not externally differ much from a healthy gland, but 
upon slight pressure it exudes a yellowish-white, viscid, semi- 
fluid alkaline substance which, when examined microscopic- 
ally, shows the presence of pus. Upon section the tissue 
of the gland is found to be denser than normal, with scat- 
tered deposits of fibrinous exudation. 

The nails also suffer, and in the inherited as in the ac- 
quired type the disease appears under two forms. When it 
occurs with the earlier and lighter lesions, it usually consists 
of a mild form of inflammation of the matrix, which latter 
is not destroyed, so that the nail itself recovers from the attack, 
merely showing for a longer or a shorter time an irregular 
or thickened condition of the nail itself, together with, at 
first, a yellozvish discoloration which later on becomes of a 
dark, broivnish color, and the nail grows irregularly. When 
this occurs later on, however, the matrix itself is destroyed, 
and the nail is either entirely and permanently lost or else, if 
a portion of the matrix remain, the nail, which comes out, 
is disfigured, thickened, distorted, and of a dirty rusty color. 



HEREDITARY SYPHILIS AND ITS TREATMENT. 1 29 

The hair is also affected in the form of an alopecia which 
may be general : that is to say, wherever hair grows upon 
an infant child — the scalp, eyebrows, and eyelashes. But in 
the early stage the hair, under proper treatment, grows 
again ; later on, however, the hair follicles may be so 
changed as to render the child permanently bald, but with 
this peculiarity, that the baldness is not general ; it occurs 
in bands or patches, usually occupying the frontoparietal 
regions, and is seldom seen upon the vertex, either frontal 
or occipital. In this also the eyebrows or eyelashes may be 
either scanty or sometimes entirely absent. 

The teeth have for a long time been recognized as one 
of the favorite points of attack in inherited syphilis, and to 
Mr. Hutchinson, of London, is due the credit of first call- 
ing attention to them ; but his views, with further observation 
and knowledge, have been much modified to what they 
were when he first wrote. In syphilitic children the decidu- 
ous teeth are friable, small, irregular, and dirty looking ; 
they frequently seem to crumble off close to the gum and are 
incapable of doing much work. This is especially notice- 
able at the time of the second dentition, or when the perma- 
nent teeth make their appearance. They then present many 
curious points. In the first place, the two central incisor 
teeth of the upper jaw are frequently widely separated from 
each other, and instead of presenting the even, chisel-like 
edges which sound teeth should, they may be either notched 
at their cutting-edges in a crescentic shape, presenting some- 
what the appearance of a new moon, or they may be beveled 
away at their cutting-edges so as to resemble a screw-driver. 
These are called crescentically notched teeth and screw- 
driver teeth. Besides this, they are very apt indeed to have 
a furrowed appearance, as though portions of their enamel 
had been gouged out. Besides this, the lower incisor 
11 



130 VENEREAL DISEASES. 

teeth present a serrated appearance, like the teeth of 
a saw, and have a very peculiar look when the child 
opens its mouth, or particularly when it retracts its upper 
and lower lips, exposing the front teeth placed against their 
edges. The teeth, furthermore, are discolored, dwarfed, 
irregular, and also frequently turn black and crumble away 
down to the edges of the gum. 

The eyes also are invaded, and the child may suffer both 
from keratitis and iritis. Of the former, there is one peculiar 
variety which is nearly always associated with hereditary 
syphilis, and is known as interstitial punctate keratitis. This 
form of disease begins in the interstitial layer of the cornea, 
rapidly invades Descemet's membrane, and appears as 
numerous, minute white dots scattered throughout the tissue. 
Connected with it there may or may not be ulceration of the 
upper layers of the cornea. This form of disease is in- 
sidious in its attack, and is seldom attended with much in- 
flammation of the conjunctiva. 

Syphilitic iritis of hereditary origin is a serious matter, as 
it is usually attended with an abundant effusion of lymph, 
which ma}* result in completely blocking up the pupil and 
rendering the patient blind. Even if it do not go so far 
as this, adhesions nearly always occur between the free 
edge of the pupil and the anterior capsule of the lens. The 
disease rapidly spreads to the deeper tunics of the eye, the 
choroid, and the retina, producing serious impairment of 
vision. 

The ears also are affected, the first symptom noted being 
a discharge. Upon examination it is found that the ex- 
ternal auditory cajial is highly inflamed, is often the seat of 
tile -crated mucous patches, and the membrana tympani has 
been perforated and lost by suppuration. This condition 
may be associated with inflammatory troubles of the middle 



HEREDITARY SYPHILIS AND ITS TREATMENT. 1 3 I 

ear, accompanied by a greater or less degree of deafness, 
which, however, is not usually associated, at least during the 
earlier stages, with any affection of the nerves : that occurs 
in the late forms of the disease. 

The internal viscera may also be affected, and if the child 
is born syphilitic and so profoundly poisoned as to die 
shortly after birth, the various organs — the lungs, heart, liver, 
spleen, stomach, intestines, kidneys, bladder, in fact, all of the 
internal viscera — may show signs of gummatous infiltration 
in various stages. If the poisoning of the child be less pro- 
found, internal visceral disturbances, while present in the 
shape of jaundice, enlargement of the liver and spleen, and 
various intestinal disturbances, are usually remediable and 
disappear or are held in check by proper treatment. It is 
in the later stage of the disease that affections of the viscera 
are more prone to occur and in which they work oftentimes 
great disturbance and trouble. In the male child the tes- 
ticles are sometimes affected, and the symptoms are enlarge- 
ment and hardness of the testicle without any pain. As a 
rule, the body of the testis itself is implicated, not the epi- 
didymis ; but this is not invariably true, as there are some 
cases reported where this portion of the testicle was affected. 
The infiltration of the testis may become absorbed under 
treatment, when from atrophy the testis itself may disap- 
pear, or else the organ breaks down from softening of the 
infiltration, and the same result — loss of the organ — is in- 
duced by suppuration. In girl children, there being prac- 
tically 110 uterus or ovaries at this tender age, so far as I am 
aware, no syphilitic lesions of these bodies are noticed, but 
they are noted when the child grows up to womanhood. 

The bones are also the seat of trouble with the rest of the 
body, and there is one variety particularly to which atten- 
tion has been called, to wit : the swelling of the fingers and 



132 VENEREAL DISEASES. 

toes, or, as it is known, dactylitis syphilitica. It is also 
attended with some degree of redness and pain. If left 
untreated, this swelling breaks down, opens in one or more 
places, and is frequently associated with dead bone, being 
analogous to what happens in the late stages of acquired 
syphilis, and may indeed be regarded as a gumma of the 
periosteum of the bone. Under treatment the swelling sub- 
sides in a great degree, but in very few cases entirely, some 
thickening being left behind; and where the joint is also 
affected, a stiff and deformed finger is but too often the 
result. 

If the nervous system be attacked, the disease usually 
shows itself as epileptiform convulsions or chorea, and unless 
the surgeon be aware of the possibility of syphilis as the 
underlying cause, he is apt to regard it as a case of struma 
or scrofula. 

Such children, under proper treatment, may entirely re- 
cover irom these symptoms, but under any circumstances will 
always be delicate in health, unable to withstand the attacks 
of intercurrent diseases, and liable to succumb to what would 
otherwise be trivial illnesses ; in fact, they are rotten, their 
inherited tendencies continually keeping them on the divid- 
ing-line between health and disease. 

Let us suppose that the child has passed through the 
early period of its life and has arrived at the age of puberty. 
The earlier symptoms may have been slight and leave few, 
in rare instances no, traces behind ; but suddenly at this 
time the patient is attacked with a swelling of the joints, 
notably of the knees, ankles, elbows, and wrists, less fre- 
quently of the clavicle or of the lower jaw, which comes 
on slowly without pain or any other of the concomitant 
symptoms of inflammation. This swelling goes on quietly 
and usually breaks down, giving vent to a thin, sanious, 



HEREDITARY SYPHILIS AND ITS TREATMENT. 1 33 

evil-smelling discharge, which is not purulent in the strict 
sense of the term and which is accompanied with the 
presence of dead bone, as discovered by the probe. Or, 
again, the child may be attacked with a sudden swelling 
of the hard or the soft palate, which quickly breaks down and 
ulcerates, leaving a large communicating cavity between the 
'mouth and the nose. 

In addition to these symptoms of the bone, the child may 
suffer with nervous symptoms in the shape of epileptic 
seizures, chorea, and hemiplegia and paraplegia. These 
come on suddenly with no premonitory symptoms, and can be 
referable to no cause, so far as the history is concerned. 
The nose sometimes shows evidences of trouble in the 
shape of ozena, with swelling of the nasal and maxillary 
bones. The discharge is thin, sanious, and fold- smelling, and 
oftentimes fragments of bone are brought away with the 
nasal discharge, and the bridge of the nose suddenly sinks 
from destruction and necrosis of its bony framework. 

In addition to these symptoms the young adult may show 
some lesion of the skin, which is said to have commenced 
" as a boil." The patient will inform the surgeon that a 
swelling occurred in the eclhdar tissue, which was slightly 
red, not very painfid, which was slow in its course, and 
gradually broke down; but as soon as it broke down it 
began to extend and ulcerate, being covered with a dirty gray 
floor and discharging a thin, fold discharge. It would never 
entirely heal up ; in some parts it would get well while it 
would extend in other directions ; and where it does cicatrize, 
leaves a white, puckered scar which sometimes is almost 
a keloid. This is the variety so commonly misnamed 
"syphilitic lupus" with which disease it really has nothing 
in common. These are symptoms which oftentimes puzzle 
the surgeon as to their cause and origin. In some instances 



134 VENEREAL DISEASES. 

the stigmata of previous lesions are left behind in the shape 
of an old interstitial keratitis, malformation of the teeth, and 
scars about the angles of the mouth. But not infrequently 
there are no such symptoms to give the surgeon the clue as 
to the cause. It is well in all such instances for you to bear 
in mind the possibility of inherited syphilis as a cause ; nor 
should you hesitate to suspect this as a reason merely 
because the parents or the child's family are respectable 
and apparently above suspicion. Remember, accidents will 
happen, and in syphilis, above all other diseases, it is the un- 
expected which is most likely to occur. 

In addition to these lesions, the patients will very often 
show other symptoms. For example, they are in a large 
proportion of cases undersized and evidently imdeveloped in 
a variety of ways. If a man, the genitals will be small and 
the testes undeveloped, perhaps not descended, being no larger 
than they arc found in boys of ten years of age. In women 
the genitals will also be small, the mons Veneris and axilla 
devoid of hair or but very scantily furnished. The same is 
true of the male. The mammce will be without prominence \ 
and menstruation will scarcely 'be established. Besides these 
lesions the eyes will show evidences of old inflammation, the 
teeth will be defective and malformed, the patient will be 
more or less deaf, giving the history of repeated and sud- 
den attacks of otorrhea, and there may be in addition some 
lesion of the joints, some ulceration of the bone, or some 
swelling and unhealed ulcerations of the skin, which are 
serpiginous, cicatrizing at one end and extending in another. 
In other words, you have before you clearly marked evi- 
dences of atrophy and general arrest of development. 

The mental pozuers are also defective. The patients are 
intellectually heavy and didl of comprehension, not grasping 
readily questions which are asked them ; the speech is some- 



HEREDITARY SYPHILIS AND ITS TREATMENT. 1 3 5 

times thick and stuttering, or if ulceration have occurred in 
the hard or the soft palate, the character of the voice is 
changed. It becomes nasal and indistinct, and if the larynx 
and pharynx have also succumbed to the disease, the pa- 
tient's voice is hoarse, sometimes almost aphonic. 

This is the classic picture of a case of syphilis hereditaria 
tarda, and it may be present in various stages, from a slight 
lack of development attended with an affection of one or two 
of the joints to the condition which I have just pictured for 
you. 

Fortunately for the unlucky infant, as well as for the good 
of the human race, the mortality in this class of patients is 
enormous ; from 80 to go per cent, of syphilitic babies die, and 
the earlier in the course of their extra-uterine life the symp- 
toms occur, the smaller the chances of their viability. 

Hereditary syphilis, together with the other venereal 
affections, is said to be caused by a bacterium, and in 
some cases where examination of the viscera of syphilitic 
infants has been made, streptococci have been found in the 
bulla of pcmplugus, in bone, in the liver, pancreas, thymus 
gland, and intestines, as well as in the smaller blood-vessels 
and in the interspaces of tissue. It is stated that they have 
never been found in blood-corpuscles nor in the interior of cells 
and fibrous tissue. Whether these streptococci are a cause 
of the disease or simply a concomitant independent of any 
causative effect, is yet undetermined, and it, perhaps, at 
present makes but little difference whether they are the 
cause or not. 

With regard to the etiology of hereditary syphilis there 
is, even at the present day, a vast difference of opinion. 
Many able writers contend that the father frequently is 
the sole cause of the disease in the child, without the 
mother becoming herself infected ; in other words, they 



I36 VENEREAL DISEASES. 

claim that the semen of the father will infect the ovum without 
conveying the disease to the mother. I avow myself an abso- 
lute disbeliever in this doctrine ; I do not believe that a 
mother can give birth to a syphilitic child without being 
herself diseased ; and I hold that if the mother be not syph- 
ilitic, the children are not, no matter what the father maybe. 
As in a work like this it would be impossible to enter into 
a lengthy discussion of the pros and cons of the case, I must 
be satisfied to tell you the bare fact, and to express the 
belief that your future practice will confirm my statement. 
Be it correct or not, here is the practical point for you to 
remember when you are called upon to treat syphilitic babies : 
include the mother in the treatment as well ; the father also, 
if you can, but the mother always, else you will be chagrined 
to find that subsequent pregnancies are followed by syphilitic 
children. 

Syphilis in its earlier stages, especially if it be of a mild 
type, may show very few and slight symptoms, and even if 
the manifestations attract notice, the woman, from notions 
of delicacy, or more frequently from ignorance of their im- 
portance, will give the surgeon no history whatever. Re- 
member, also, that the earlier lesions leave no traces behind 
them, and this, conjoined with the fact that pregnancy often 
exerts an influence in holding the earlier manifestations of 
syphilis in check, leaves the surgeon absolutely in the dark 
as to the cause of the child's syphilis. He then turns to 
the father, and if the unlucky wight has happened to have 
contracted syphilis as a bachelor, although before marriage 
he has entirely recovered, the disease of the child is laid upon 
his shoulders, to the great comfort of the surgeon and the edi- 
fication of all concerned, except, perhaps, the father. Some- 
times, however, he absolutely denies any previous disease, and 
the case is then consigned to the limbo of unknown causes. 



HEREDITARY SYPHILIS AND ITS TREATMENT. 1 37 

Syphilis is also a fruitful cause of abortions ; and where, 
in any given case, repeated pregnancies have ended in mis- 
carriage, this latter should always be regarded as suspi- 
cious, and the possibility of syphilis being the cause enter- 
tained, no matter if the ivoman at the time shows no symptom 
of the disease. 

The treatment in these cases, to be of any avail, must be 
prompt and thorough ; and here, as in the acquired form of 
syphilis, mercury is the main reliance. It is of little use to 
attempt to treat the child through the mother s milk — that 
is, by putting the mother upon treatment ; because, in the 
first place, it is very doubtful if the mercury be excreted by 
the mamma?, and, in the next place, if so, the amount is 
very small — too small indeed to be of any service. The 
inunction method in this form of the disease is by far the best, 
and should be practised in the following manner : a drachm 
of the oleate of mercury (20 per cent.) should be evenly 
spread upon a piece of cloth or thin flannel a foot wide, and 
long enough to go round the baby's body ; this should 
be applied like a swathe, and the mercury should be re- 
newed every second or third day. Children in this condition 
stand mercury remarkably zvell, and the only care taken 
should be to see that this strength of the ointment does not 
irritate the skin ; if it does, a weaker solution of the oleate 
should be used, or else freshly prepared mercurial ointment. 
In addition minute doses of either the bichlorid of mercury or 
of gray powder may be given internally — the bichlorid in 
doses of from t -J-q- to -^ of a grain, three or four times daily, 
in milk which has been diluted with one-half its own quan- 
tity of water, and slightly warmed ; the gray powder in 
three- or five-grain doses, placed directly upon the tongue. 
Iodid of potassium in these cases is useless, and the treatment 
should be confined to the use of mercury alone. 



I38 VENEREAL DISEASES. 

As regards the child's nursing, no one but the mother 
should be allowed to suckle it, inasmuch as the mucous patches 
which are nearly always found in this stage of infantile 
syphilis are eminently contagious , and you have no right to 
expose an otherwise healthy woman to the risk of infection. 
It is a curious fact, which was pointed out as early as 1837 
by Dr. Abram Colles, of Dublin, that the mothers of syph- 
ilitic children, although they themselves may show no signs 
of the disease, are not obnoxious to contagion from syphilis ; 
hence, the child may, with impunity, suckle its apparently 
healthy mother, where it would be a source of danger to 
any healthy stranger who should attempt to perform the 
maternal function. If the mother should be unable to suckle 
the child, it must be weaned and brought up on the bottle. 

Supposing the child to recover from its earlier symp- 
toms, — the mercurial treatment having been continued, of 
course, until all manifestations have disappeared, — it should 
be placed upon a tonic treatment, and kept under observation 
for a couple of years. It may then be dismissed with the 
injunction to the parents that fresh symptoms must be expected 
when the child arrives at the age of puberty; and should any 
manifest themselves either at that time or before, the child 
must at once be placed under medical observation. As I have 
already pointed out to you, the symptoms which present 
themselves at the period of puberty are analogous to those 
which occur in the later stages of acquired syphilis, viz. : 
nodes of the bones, diseases of the nervous system, and ulcera- 
tions of the mouth and throat. Here it is that you find the 
iodid of potassium coming into play as a feature in the treat- 
ment, but not, I beg you to remember, to the exclusion of 
mercury ; for you will obtain the best results where you 
combine the two. 

This may be done in the following manner : 



HEREDITARY SYPHILIS AND ITS TREATMENT. 1 39 

R. Hydrarg. bichlor., .... gr. ss-j 

Kali iodidi, 3J 

Syrup, aurant. cort., vel 

Syrup, sars. comp., q. s. ad^ij. 

M. 

SlG. — Teaspoonful in water three or four times daily. 

If it be preferred to give the two separately, the pill of 
the protiodid of mercury may be given once daily, in *^ or 
^ of a grain dose, and the iodid of potassium twice or thrice 
daily, before meals, in the following prescription : 

R . Kali iodidi, 5J-ij 

Syrup, sars. comp., ^ij. 

M. 

SlG. — In teaspoonful doses. 

If the iodid should not be well borne, the tincture of 
iodin may be substituted, as follows : 

R. Tinct. iod., 39~* v 

Syrupi fusci, if n j- 

M. 

SlG. — Teaspoonful three times daily. 

All these preparations in which the syrups enter should 
be made in small quantities, and freshly prepared, as the 
syrup is liable to undergo fermentation when long kept. 

In the intervals between the mercurial and iodic treatment 
one of the best tonics for internal administration is the syrup 
of the iodid of iron, either alone or in combination with cod- 
liver oil, and the syrup of the hypophosphites of lime or soda. 
This latter is particularly to be commended in the osseous 
and nervous lesions of inherited syphilis. 

The following prescriptions will be of service : 

R. Syr. ferri iod., t ^ij. 

SlG. — Five to ten minims three times daily after meals. 

R . Syr. ferri iod. , 3 iv 

01. morrhuae, 5 hi. 

M. 

Shake well before using. 

SlG. — Teaspoonful after meals thrice daily. 

R . Syr. calcis et sodas hypophosph. , . . . . ^ ij. 
SlG. — In teaspoonful doses twice or thrice daily. 



I4O VENEREAL DISEASES. 

This may be combined with cod-liver oil, if deemed desir- 
able, in the same doses as given above. 

The old manner of giving the iodid of iron in pill form — 
what is sold under the name of Blancard's pill — is not so 
good as the symp, inasmuch as the pills, if kept for any 
length of time, are apt to become hard, and are not easily 
acted upon by the intestinal juices. 



CHAPTER X. 
GONORRHEA OF BOTH SEXES. 

Gonorrhea, or, as it is more commonly called, clap, is 
one of the most common forms of venereal disease which 
you will be called upon to treat, and oftentimes one of the 
most obstinate and rebellious to treatment. I shall consider 
it, first, as it affects the male ; second, as it affects the 
female: It is a local disease, sometimes accompanied by con- 
stitutional symptoms ; it is very contagious, and is usually 
contracted by one person from another at the time of coitus. 
This is known as direct contagion. Gonorrhea may, how- 
ever, be conveyed from one person to another by the 
medium of sponges, syringes, and other articles which have 
previously been used by an individual suffering from some 
form of the disease. This is known as indirect contagion, 
and is seen much less frequently than direct infection. 

Gonorrhea is characterized by a specific micro-organism, 
the gonococcus, described by Neisser in 1879. This specific 
coccus usually appears as a diplococcus, and may invade 
any part of the genito -urinary tract of either sex. Other 
parts of the body are occasionally invaded by the gonococ- 
cus. With the exception of the genito -urinary organs, 
the eyes are the organs most frequently attacked, either 
directly or indirectly. Ophthalmia neonatorum is the result 
of a gonorrheal infection usually produced by direct con- 
tact with the mother's diseased genital organs. By the 
medium of the hands the eyes of gonorrheal patients are 
occasionally infected. The rectum may also be the seat of 

141 



142 VENEREAL DISEASES. 

trouble. This is more frequently the case in women than 
in men, owing, in the former, to the relative position of the 
rectum and vagina. The discharge from the vagina, by 
the force of gravity, flows over the anus, and in this way 
may invade the rectum. The direct introduction of the 
gonococci by coitus is occasionally observed. When pres- 
ent in men and boys, such an occurrence is practically 
always the result of sodomy. Other parts of the body 
invaded by the gonococcus, as demonstrated by bacterio- 
logical tests, are the joints, tendons, not infrequently the 
endocardium and pericardium, the pleura, the peritoneum in 
the female, various glands of the body, and the mouth and 
throat. Intramuscular and subcutaneous abscesses, and 
rarely septicemia, have also resulted from gonorrheal in- 
fection of the urethra. Much discussion has followed as 
to the etiological importance of the gonococcus, but as 
Neisser demonstrated its presence in a large majority of 
cases of urethritis, this specific micro-organism is at the 
present time accepted by nearly all authorities as pathog- 
nomonic of gonorrhea. In order to make a positive diag- 
nosis of gonorrhea we must demonstrate the presence of 
the gonococcus in the suspected discharge. A gonorrhea 
can only be produced by the entrance into a person's genito- 
urinary tract of the diplococais of Neisser, which is never 
present in healthy subjects of either sex. The virulence of 
the gonococcus, however, varies in different individuals, 
and in consequence the course of the disease is variable. 

If the gonococcus be absent from a suspected discharge 
of the genito-urinary tract in the male or female, the dis- 
ease is usually the result of a simple or nonspecific inflam- 
mation. In a small proportion of patients an urethral 
discharge in the male may be caused by intra-urethral 
chancroids, the initial lesion of syphilis, and occasionally 



GONORRHEA OF BOTH SEXES. I43 

by tuberculosis of some portion of the urethra or contiguous 
parts. 

The differential diagnosis of these various forms of in- 
flammation, as can readily be seen, is often of vast impor- 
tance, first, as it affects the treatment of the case ; next, as 
it may affect some one's good name and reputation, and 
last, in its relation to the community at large. 

After obtaining a careful history of the patient we should 
in all cases make a local examination of the parts involved. 
Never take the patient y s unsupported zuord for any venereal 
manifestation. After the parts have been exposed and 
superficially examined, a drop of the suspected discharge 
should be pressed from the urethra and placed on a clean 
cover-glass. Another cover-glass is gently pressed over 
the first ; by a quick, sliding motion the glasses are then 
separated, and allowed to dry in the air. The fraction 
of a drop of the exudate is in this manner pressed between 
the cover-glasses into a thin film. The glasses thus pre- 
pared should be carefully heated over a Bunsen burner or 
an alcohol lamp. In this way the suspected discharge is 
" fixed" on the cover-glasses so that it will not wash off, 
and is then ready to be stained for examination. 

The gonococci are coffee-bean or biscuit shaped, found 
almost always in pairs , with their concave surfaces parallel 
and facing each other. The distance between the concave 
surfaces is about equal to one-half their individual width. 
They are found abundantly within the capsule of the pus- 
cell and outside of the nuclei, and particularly so in the early 
stages of gonorrhea ; as the disease subsides they become 
fewer and fewer, and finally, as the case recovers, disappear. 

In some cases a few of the diplococci are found outside 
of the pus-cell, while others are situated as already de- 
scribed. We can sometimes account for this on the assump- 



144 VENEREAL DISEASES. 

tion that too great pressure dislodged them at the time of 
the preparation of the cover-glasses. 

In a small percentage of cases, however, another diplo- 
coccus closely resembling the gonococcus in its general ar- 
rangement has been demonstrated in urethral or vaginal 
discharges, and it is to the occasional presence of this non- 
specific diplococcus that we, no doubt, owe much of the con- 
fusion which has prevailed in regard to the etiological 
importance of the gonococcus. 

After we have taken, as described above, some of the 
discharge for examination, the male patient should be 
directed to pass the urine in two glasses, its appearance 
carefully noted, whether cloudy or not, and in which glass 
the cloudiness is more marked. The character of the 
"Tripperfaden" or clap -threads, and in which part of the 
urine they are most prominent are of importance in deter- 
mining the position of the diseased area. In acute ante- 
rior urethritis the first urine voided is more cloudy than the 
second. This matter will be considered more in detail 
later on. 

The specific gravity of the urine, its reaction, color, and 
the presence or absence of albumin and sugar should in 
certain cases be carefully noted and a microscopical exam- 
ination of the urinary sediment made. 

The next step in our examination is to determine the 
condition of the prostate and seminal vesicles. 

In acute urethral inflammation no examination of the canal 
should be made, but in the subacute and chronic forms it 
may be explored with the endoscope, and in these latter 
cases we may also investigate the urethra with an olive- 
tipped bougie for strictures. If the prostate and seminal 
vesicles are normal, sounds may be passed into the deep 
urethra and bladder, but otherwise, in the majority of cases, 



GONORRHEA OF BOTH SEXES. 145 

it is best not to do so. The anterior urethra should be 
washed out with a mild antiseptic solution before instru- 
ments are passed. 

It is well to remember that a discharge appearing at the 
meatus may indicate disease of any portion of the urethra, 
the seminal vesicles, the prostate, Coivper s glands, etc. ; 
therefore to employ an anterior urethral injection as routine 
treatment in such cases is not only useless, but frequently 
aggravates the disease. 

Gleet is a word we hear frequently. In its strict sense 
it is used to designate the " morning drop " in cases of 
chronic gonorrhea, and is usually the result of stricture. 
The term, however, is synonymous with chronic gonorrhea, 
and is a convenient cloak for ignorance, for it tells nothing 
as to the seat of the disease. As already stated, we should 
determine by our examination the part of the genito-urinary 
tract involved and describe the disease accordingly. 

When there is a question as to the fidelity of a husband 
or a wife, a great deal depends upon the medical adviser in 
his management of the case, and in such a contingency it 
is most unwise to immediately presume that a discharge is 
of gonorrheal origin. Before expressing an opinion obtain 
a history of the patient, then make a local examination of 
the parts, and finally examine carefully for the gonococcus. 

Gonorrhea is occasionally the cause of sterility in both 
men and women ; particularly is this the case when there is 
a history of the epididymis, the seminal vesicles, the pros- 
tate, etc., in the male, and the uterus and its appendages in 
the female, having been invaded by the disease. 

Gonorrhea has an incubation period of from three to seven 
days, usually appearing, however, within seventy -tzvo hours 
after the suspicious coitus ; the first noticeable symptom 
is a slight tickling just within the meatus, which becomes 



I46 VENEREAL DISEASES. 

more marked during micturition. If pressure be exercised 
along the floor of the urethra, a drop or two of sticky fluid 
can be squeezed from the end of the penis. This fluid is 
thin, colorless, and does not stain the linen. After twenty- 
four to forty-eight hours have elapsed the discharge will be 
seen to have lost the characteristics just detailed, to become 
thicker and white, like milk, and the act of micturition is more 
painful. If the disease be left to itself, the discharge be- 
comes more and more abundant, sometimes so much so as 
to drip from the patient ; it loses its white appearance and 
becomes yelloiv and, if the inflammation is acute, of a 
greenish or rusty hue, from the admixture of blood. The 
act of urination now becomes decidedly painful, the stream 
of water very much diminished in size, and when the inflam- 
mation is high, the water is only passed drop by drop. Where 
this condition of things obtains, febrile symptoms are often 
present, particularly in a first attack, attended with a high 
pulse, hot and dry skin, and a furred tongue. The penis is 
edematous and swollen, and where the prepuce is long, the 
edema may be so great as even to cause partial or complete 
phimosis. The lymphatics on the dorsum penis are enlarged, 
red, and painful, and the glands in the groin may also par- 
ticipate in the general inflammation, becoming, in their turn, 
swollen and tender. 

In other cases the inflammatory symptoms may be en- 
tirely absent, the only signs present being painful micturition 
and a purulent discharge. This usually reaches its height 
about the tenth day, invading in its progress the urethral 
mucous membrane from the fossa navicularis, the starting- 
point of the disease, to the region of the bulbus urethrae. 
At this date the discharge retains its yellow character, but 
the act of micturition is less painful than during the first few 
days of the disease. It then remains stationary for another 



GONORRHEA OF BOTH SEXES. 147 

ten days or so, when the discharge gradually loses its puru- 
lent and yellow character, changing to white, and from that 
to a thin, viscid, colorless flow, running, but in a descending 
scale, through the same course that it pursued in its com- 
mencement. As the discharge becomes less and less puru- 
lent the act of micturition becomes easier, until finally all 
pain and discomfort cease. Gradually this thin discharge 
diminishes, until it finally dries up entirely, and the patient 
finds himself well. This is the course usually pursued where 
no complications are present ; where these occur, however, 
the disease is of much more prolonged duration, is more 
painful and serious ; but of these I shall speak in a separate 
chapter. 

You would be wrong should you consider that all urethral 
discharges in men are of gonorrheal origin. Undoubtedly 
the majority of such discharges are caused by the gono- 
coccus, but we also have other factors at work which must 
be carefully differentiated. 

A simple urethritis is one zvhich has no specific micro- 
organism. It is sometimes prodiiced by staphylococci, strep- 
tococci, or other bacteria which may have been present in a 
leucorrheal or menstruating; woman at the time of coitus. 
On the other hand, a simple urethritis in a man may be 
caused by an irritating injection, by the improper use of 
urethral instruments, or by excessive and unnatural meth- 
ods of sexual excitement. In many cases of simple ure- 
thritis the discharge appears within a few hours, is mild in 
type, and disappears sooner than a gonorrhea. In other 
cases, however, the clinical history is very similar to that of 
a gonorrheal infection, and can only be differentiated by a 
microscopical examination of the discharge. In patients 
who have had a previous gonorrhea, who are debilitated, 
or who are suffering from tuberculosis we must be guarded 



I48 VENEREAL DISEASES. 

in making a diagnosis of a fresh gonorrhea, and espe- 
cially so in the last cases, where we occasionally find a 
tubercular process grafted on an old gonorrheal infection. 
Such cases are extremely obstinate to all methods of treat- 
ment, and when such a condition is suspected, the discharge 
should always be examined for the tubercle bacilli. 

The old theory that gonorrhea may be produced in a man 
by coitus with a healthy woman is now known to be erroneous. 
In such cases the disease is usually a simple urethritis. An 
urethral chancroid, the ifiitial lesion of syphilis, and gout will 
also produce a running from the genitals, and it is often- 
times difficult to decide at once whether the disease under 
observation is really gonorrhea or not. If the cause be due 
to a concealed chancroid, the following symptoms will serve 
to put you upon the right track. The pain in the urethra is 
localized, and not general, as it is in clap"; the discharge, 
although purulent, is 7iot very abundant, and is frequently 
streaked with fresh blood, and pressure along the floor of the 
urethra excites pain only at the scat of the lesion. The 
crucial tests, however, are the microscope and auto-inocula- 
tion. Separation of the lips of the urethra will often dis- 
close the sore seated just within the meatus ; but if, as 
sometimes happens, it is situated deeper within the canal, 
the examination must be conducted in another manner. An 
instrument known as the endoscope or urethroscope should 
be employed to differentiate the above-mentioned condi- 
tions. This instrument is passed a short distance into the 
urethra, and by the aid of an electric light projected through 
the tube we can plainly see the diseased area. Sometimes 
a wire frame speculum affords a better view than the endo- 
scopic tube. 

If, however, the discharge be due to a concealed initial 
lesion, the symptoms are somewhat different : the discharge 



GONORRHEA OF BOTH SEXES. 1 49 

is very thin, and seldom becomes purulent, unless irritated 
from some cause or another. Palpation reveals, in the 
majority of cases, an indurated spot in the course of the 
canal, and an examination of the urethra by the method 
already advised gives the clue to the proper source of the 
urethral discharge. Besides these causes, gouty persons 
are very liable to slight discharges from the urethra ; and 
especially after the patients have indulged a little more 
freely than usual in the pleasures of the table, particu- 
larly in the use of heavy-bodied wines, such as Burgundy 
or port. Here the disease comes on without any history 
of sexual indulgence, and is attended with pain near the 
neck of the bladder and along the course of the prostatic 
urethra during micturition. The discharge which accom- 
panies this form of disease is not very abundant, although 
it may be slightly purulent ; it stains the patient's linen, and 
comes from the deeper part of the canal — never from the 
anterior portion, as in clap. The urine is very acid and 
loaded with urates. Under proper treatment these symp- 
toms usually abate in the course of a week, leaving the 
patient as well as he was before. 

Tight strictures of the deep urethra may also cause a 
mucopurulent discharge ; but as a consideration of these 
diseases belong rather to the domain of surgery than of 
venereal medicine, I shall content myself with a mere men- 
tion of this as an exciting cause. 

From what has already been said, the importance of 
differentiating between a gonorrhea and other causes of in- 
flammation of the genito-urinary tract is very apparent. 

The duration of gonorrhea, as I have already told you, 
varies very much in different individuals. In women it may 
last for several months or even years, and is frequently one 
of the most obstinate diseases to treat. This is particularly 



150 VENEREAL DISEASES. 

the case when the gonococci invade the mucous membrane 
of the uterus and the other genital organs. In men, how- 
ever, although sufficiently obstinate, it is not, as a rule, so 
chronic as in women ; this is due in great measure to the 
greater care and persistence with which the treatment is 
carried out. In men tlie disease, unless complicated, usually 
runs its course in from four to eight weeks ; but if any of 
the complications supervene, of which I shall speak more 
fully in another chapter, the disease may be prolonged many 
months or even several years. Much depends upon the 
fidelity with which the patient carries out the treatment, and 
he should be particularly cautioned to continue it for a 
short time after apparent recovery has taken place, because 
gonorrhea is very prone to relapse, and each relapse makes 
the disease more difficult to cure. 

In women the affection may show itself first as an inflam- 
mation of the vulvar mucous membrane, invading the vesti- 
Inde and the labia majora ct minora. Micturition is at- 
tended with some smarting and pain, due to the acid urine 
passing over the irritated and inflamed mucous membrane. 

Vulvitis is of frequent occurrence, and is generally at- 
tended with erosions of the nnicous membrane of the vulva, the 
vestibule, and the fourchette, with a copious mucopurulent 
discharge which, flowing over the perineum and the insides 
of the thighs, irritates and excoriates these parts. If the 
inflammation is very acute, the labia majora become ede- 
matous and szvollcn, sometimes ending in suppuration. 

The glands of Bartholin, the ducts of which open within 
the introitus vaginae, may participate in an attack of vulvitis, 
both being involved at the same time, although the attack 
is usually unilateral. The inflammation presents itself as an 
ovoid swelling situated at the posterior commissure of the 
labia majora, and nearly always ends in suppuration, follow- 



GONORRHEA OF BOTH SEXES. I 5 I 

ing one of two courses : either the pus is evacuated through 
the duct into the vagina or occlusion of the duct ensues, 
requiring an external incision for cure of the swelling. 

In urethritis the most common site of the disease, the 
canal, is seen to be red, swollen, and secreting an abundance 
of thick yellow pus. If the discharge is not apparent to the 
eye, after the urethral orifice has been wiped clean, a 
finger may be introduced into the vagina, and by stripping 
the urethra we can usually force out a few drops of pus. 
Where you find the urethra in women the seat of a muco- 
purulent discharge, you may say with confidence that the dis- 
ease is gonorrhea ; for no leucorrhea that I am conversant 
with is attended with a discharge from the urethra. 

Stricture of the urethra is comparatively rare in women, 
and when it does occur, is usually seated near the meatus. 

Vaginitis, though usually considered the most common 
form of gonorrhea in women, is now known to be present 
much less frequently than urethritis or endometritis. The 
disease begins as a thin, viscid, colorless discharge, analo- 
gous to what occurs in the male, which speedily becomes 
thick, abundant, and purulent, staining the woman's body- 
linen. This inflammation usually extends from the urethra, 
vulva, or cervix to the vagina, which upon examination is 
seen to be red, swollen, and secreting a copious amount 
of thick, yellowish pus. The temperature of the parts is 
also increased. After lasting for several weeks the dis- 
charge diminishes in intensity and purulence, and the 
mucous membrane of the vagina becomes less red and 
swollen, although the discharge may continue for some 
time longer. It now, however, becomes of a light' yellow 
or white color, closely resembling an ordinary leucorrheal 
discharge. When this stage is reached, unless subjected 
to treatment, it remains stationary for a long time, being 



152 VENEREAL DISEASES. 

liable to exacerbation from various causes, until it gradually 
wears away to the thin, viscid discharge which marked the 
advent of the disease. Pain is no longer felt during mic- 
turition, as the mucous membrane of the vulva becomes 
thickened and is no longer sensitive. 

Ordinarily a gonorrheal vaginitis when not complicated 
is not a serious affair, and is usually cured in from three to 
four weeks. In prostitutes, however, the disease commonly 
becomes chronic, and we find a dry, roughened condition of 
the vaginal mucous membrane. In women as in men the 
disease is liable to become chronic, particularly if the uterus 
and the Fallopian tubes have become involved. The gono- 
cocens may remain inactive for years in the mucosa of the 
uterus. A woman with a latent gonorrhea may infect a 
healthy man who has had coitus with her at or about the time 
of menstruation, while at other times the same man would 
be unaffected. This possibility partially accounts for the 
fact that one man becomes infected with gonorrhea while 
another having sexual relations with the same woman 
escapes all contagion. The reason for this is that during 
the menstrual period the endometrium is congested, and 
with the flow are dislodged some of the gonococci which 
are at other times buried and consequently harmless. 
Such a condition, while in a quiescent state, is extremely 
difficult to diagnosticate. On the other hand, man)- a healthy 
young woman becomes after marriage an invalid, or worse, 
through the invasion of the gonococcus from the husband. 
Such a condition of affairs frequently comes under the 
observation of the gynecologist and is a common cause of 
operative procedures. In many of these cases the husband 
has been previously infected by gonorrhea which, in many 
instances without his knowing it, still lurked in some part 
of his genito-urinary organs at the time of his marriage ; 



GONORRHEA OF BOTH SEXES. 153 

which possibility only again emphasizes the etiological 
importance of the gonococcus. I will tabulate for you the 
following axioms : 

Gonorrhea is characterized by a specific micro-organism, 
the gonococcus of Neisser. This specific diplococcus is never 
present in the healthy genito-nrinary tract of the male or 
female. 

Inflammations of the genito-nrinary organs of both sexes 
are frequently produced by causes other than the gonococcus 
of Neisser. 

A positive diagnosis of gonorrhea can not be made until 
the presence of this specific diplococats has been demonstrated 
in the discharge. 

Both sexes, having had a previous gonorrhea t may become 
tolerant to the presence in their genito-urinary organs of this 
diplococcus, which, however, when introduced into the healthy 
genitals of a male or female, will usually produce an acute or 
subacute gonorrhea. 



13 



CHAPTER XI. 

COMPLICATIONS WHICH OCCUR IN 
GONORRHEA. 

The complications which occur in gonorrhea are numer- 
ous, and some of them, as previously stated, are of a very 
serious nature. Any part of the genito-urinary tract and 
various other regions of the body in both sexes may be 
invaded by the gonococcus. Only the more common com- 
plications, however, will be described here. 

The first to be considered is balanoposthitis, which is 
an inflammation of the glans penis and the mucous mem- 
brane of the prepuce. Balanitis is an inflammation of the 
glans penis alone, while posthitis means an inflamed state of 
the mucous membrane of the prepuce. However, as they 
usually occur in combination, the condition will be described 
under the name of balanoposthitis. Gonorrheal pus acting 
as an irritant to this region is frequently a cause of inflam- 
mation. This is particularly the case in those who are 
uncleanly or who have a redundant foreskin. Chancroids, 
syphilis, and various forms of irritating menstrual and leu- 
corrheal discharges in the female may also cause balano- 
posthitis. 

Microscopical examination of the secretion, combined 
with the history of the case, will usually clear up any doubt 
as to the primary cause of the disease. The affection is 
characterized by intense redness of the parts, and is attended 
with slight excoriations which may easily be mistaken for 
chancroids or for mucous patches ; but their superficial 

iS4 



COMPLICATIONS WHICH OCCUR IN GONORRHEA. I 55 

character and the readiness with which they yield to the 
simplest treatment will differentiate them from the former, 
and the absence of concomitant symptoms, as well as of all 
history of syphilis, will exclude them from the category of 
syphilitic manifestations. They usually appear as mere 
erosions of the mucous membrane, and seldom, unless 
irritated, are they covered over with any secretion. If a 
pellicle form over the abraded points, it can be readily re- 
moved. 

In phimosis the foreskin is incapable of retraction. Men 
with redundant or tight foreskins are more likely to suffer 
from phimosis. This condition frequently makes the diag- 
nosis and treatment of gonorrhea very difficult, and when 
it is extreme and continues unrelieved, sloughing of the 
parts may ensue. Besides gonorrhea as a cause for this 
disease, chancroids, the initial lesion of syphilis, and, occa- 
sionally, a simple balanopostliitis produce a similar condi- 
tion. It is extremely difficult in many of these cases of 
phimosis to determine the specific cause of the trouble, be- 
cause the foreskin is usually so inflamed and swollen that a 
view of the meatus can not be obtained. In all instances we 
should ascertain as soon as possible whether or not the dis- 
charge comes from the meatus, inasmuch as the treatment 
of the case depends largely upon the determination of this 
point. 

Usually combined with a gonorrheal phimosis we have, in 
addition to the discharge from the urethra, an inflammation 
with a discharge of pns from under the foreskin. This 
secondary condition is caused by the backing-up of the 
gonorrheal pus, resulting in an involvement of the whole 
foreskin and glans. We occasionally find a chancroidal or 
syphilitic infection of the glans and foreskin combined with 
a gonorrheal discharge from the urethra. 



156 VENEREAL DISEASES. 

To make a diagnosis we should carefully syringe out the 
foreskin, and direct the patient to urinate, when, if the urine 
thus voided is cloudy, the discharge conies from the urethra. 
Phimosis is usually painful, particularly during the act of 
urination, and the whole penis occasionally becomes edema- 
tous and enlarged to twice its natural size. 

Paraphimosis is a condition of persistent retraction of 
the foreskin behind the glans. Here the meatus is exposed, 
so that the question as to the source of the discharge is not 
raised. This complication is more frequently seen in the 
early stage of gonorrhea, particularly so in cases of men 
with short foreskins. If the swelling be very severe and the 
constriction behind the glans very tight, sloughing and even 
gangrene of the penis are liable to occur. The edema is 
usually very marked and extremely painful ; the glans 
becomes purple, the temperature is reduced, and the parts 
may slough from mechanical obstruction to the circulation. 

Inflammation of the Glands of Littre and of the 
Lacuna Magna. — These glands are situated in the anterior 
urethra, with the openings of their ducts pointing toward 
the meatus. They occasionally become diseased in gonor- 
rhea, and may give rise to a very persistent discharge. 
With the endoscope the openings of the ducts can be seen, 
which by the application of a little external pressure may 
be made to discharge pus. The possibility of a discharge of 
long standing having its origin in one of these little glands 
should never be overlooked when searching for the source 
of an obscure urethral discharge. 

Peri-urethral Abscess. — Sometimes along the course 
of the urethra one or more points become hard and exquis- 
itely tender, which after a time soften and break dow?t, dis- 
charging a quantity of pus. The presence of these abscesses 
is determined by palpating the floor of the urethra, on 



COMPLICATIONS WHICH OCCUR IN GONORRHEA. I 57 

which deep-seated kernels may be felt intimately associated 
with this canal. 

A complication of this kind is caused by the invasion of 
the cellular tissue outside the urethral wall by gonorrhea. It 
may occur in any portion of the urethra, but is more fre- 
quently found at the frenum, the penoscrotal angle, and the 
perineum. In most cases the inflammation presumably 
reaches the part by extension along the ducts and mucous 
follicles of the urethra. When present in the perineum, 
these abscesses usually open externally. There may be 
several of them present at one time. Whenever possible, 
it is best to open them into the urethra. They may attain 
the size of a hazelnut, and in some cases they are very 
persistent and obstinate to all form of treatment. 

If a man has once been affected with these peri-urethral 
abscesses, he is more likely to have a complication of this 
kind follow another attack of gonorrhea. In some patients 
the disease becomes quiescent, but not really cured, and it 
is liable to light up again on slight provocation. This 
is especially true in those persons with a tubercular 
diathesis. 

The improper use of urethral instruments may also cause 
urethral abscess ; occasionally stricture follows, and in some 
cases urinary extravasation results. 

Peri-urethral abscesses are usually ushered in by a chill and 
slight rise of temperature, speedily followed by the appear- 
ance of pus in the swelling, which may attain a large size. 
These often press upon the urethra in such a way as to 
diminish the calibre of the canal and interfere seriously 
with the act of micturition. 

One of the commonest complications of gonorrhea in 
the male is known as chordee, which is a painful curva- 
ture of the penis during erection. This may take place in 



I58 VENEREAL DISEASES. 

three ways : with the concavity looking downward, upward, 
or sideways, and is due to an exudation of lymph into the 
corpus spongiosum or the corpora cavernosa. This dis- 
tressing symptom comes on only during erection, and 
seems to be particularly favored by the heat and warmth 
of the bed. Sometimes the amount of inflammation and 
distortion which occurs is so great as to produce free hem- 
orrhage from the urethra, leading to temporary relief, but 
so soon as the local effect has passed off, the chordee re- 
turns as vigorously as ever. 

Cowperitis is an inflammation of the two small glands 
situated anteriorly to the prostate, and whose ducts, each 
about one inch long, open into the anterior part of the 
membranous urethra. These little bodies are occasionally 
involved during the course of a gonorrhea. 

Like the glands and follicles of the urethra, their func- 
tion is probably to assist in lubricating this canal. From 
the fact of their being surrounded by the compressor ure- 
thral muscle they frequently cause considerable disturbance 
when acutely diseased. They may be involved in an in- 
flammation of the prostate or they may be infected alone. 
Usually only one is inflamed at a time, but if the case be 
seen late in the attack, the whole perineum may be so 
sensitive and swollen that it is difficult to decide this 
point. 

They are situated in the perineal region, one on each 
side of the urethra. With one hand over the perineum 
and a finger in the rectum they can usually be differenti- 
ated from a peri-urethral abscess, which is always, in this 
region, in the middle of the urethra. 

Injury to the perineum, as in horseback-riding, improper 
use of urethral instruments, and tubercidosis may cause 
cowperitis. When this is the result of one of the above 



COMPLICATIONS WHICH OCCUR IN GONORRHEA. I 59 

causes, there has usually been an antecedent inflammation 
in one of the glands or its duct. 

The symptoms are great discomfort and frequent urina- 
tion, owing to the position of the glands. There will be 
marked pain, produced by any pressure over the perineum. 
The stream may be much impeded by mechanical obstruc- 
tion of the urethral canal. As pus forms there will be a 
eki.7, throbbing of the perineum, increase in the size of the 
swelling, and general constitutional symptoms. In some 
instances an abscess of Cowper's gland opens externally, 
discharging a quantity of pus, and heals kindly, but in a 
majority of cases troublesome cicatrices form which have to 
be remedied by an operation. In many instances the inflam- 
mation becomes chronic, lighting up fresh attacks on slight 
provocation. In this way a chronic urethral discharge may 
be continued for a long time, proving obstinate to all treat- 
ment. 

Prostatitis. — The prostate surrounds the neck of the 
bladder, is about the size of a horse-chestnut, and is com- 
posed of muscular and glandular tissue enclosed in a firm 
fibrous capsule. The glandular substance is made up of 
numerous follicles, which open into elongated canals, these 
in turn terminating in the urethra by fifteen or twenty ex- 
cretory ducts. 

The function of the prostate is genital. By the contrac- 
tion of this body acting with the seminal vesicles to which 
the upper portion is attached the semen is expelled during 
an emission, the follicles of the prostate secreting a fluid 
which adds to the volume of the semen at the moment of 
ejaculation. The ejaculatory ducts open by two minute ori- 
fices into the floor of the prostatic urethra. 

Gonorrheal infection of the prostate occurs in a fairly 
large percentage of cases, and with the inflammation of the 



l6o VENEREAL DISEASES. 

prostate is often associated a diseased condition of parts 
adjacent to this organ, the capsule and follicles of the pros- 
tate being the parts usually involved, and not the muscular 
tissue. 

Pelvic inflammation, seminal vesiculitis, etc., should be 
carefully differentiated from a true prostatitis. The first 
symptom which the patient notices is a sensation of uneasi- 
ness, rather than of actual pain, in the perineum, together 
with a feeling of weight and tension in the part, and this is 
particularly noticeable when he sits down. This symptom 
gradually increases until both the erect and sitting postures 
are painful, and the patient only finds relief when lying upon 
his back. Connected with this is a still more unpleasant 
symptom, viz. — a constant and urgent desire to pass water, 
which comes upon the patient so suddenly and violently that, 
no matter where he is, he has to respond at once to this call 
of nature, and the urine is voided quite as frequently in Jus 
clothing as out of it. After the water is ejected — and nearly 
always this occurs in very small quantities — there is a violent 
straining and bearing dozvn, which is present not only at the 
neck of the bladder, but in the rectum as well, as though 
the bladder and rectum needed instant evacuation. This is 
known as tenesmus, and may be so violent as to cause hemor- 
rhoids or a prolapse of the bowel. 

Upon examination through the rectum the prostate will 
be found enormously enlarged, encroaching upon the bowel, 
and most exquisitely tender, and this inflammation may 
pursue one of two courses : either the symptoms entirely 
subside and the disease passes off, or an abscess of the pros- 
tate may result. If this latter occur, it terminates either by 
breaking into the urethra-. — the most favorable of all courses 
— or else it opens into the rectum, producing a rectopros- 
tatic abscess ; or if, as sometimes happens, the abscess opens 



COMPLICATIONS WHICH OCCUR IN GONORRHEA. l6l 

in both directions, a fistula between the urethra and rectum 
is established which is extremely difficult to cure. 

The examination of the urine is important as a means of 
determining the location of the disease. The patient 
should be directed to pass his urine in two beakers, when, 
if the prostate or prostatic urethra is involved, the first and 
last portions arc equally cloudy, and this is particularly true 
when there is a large amount of pus. On the other hand, 
if the anterior urethra alone is involved, the first portion of 
urine voided will be cloudy, while the second will be nearly 
clear. 

These observations apply more to acute than to chronic 
inflammations, where the secretion is often small in quan- 
tity. In cases of posterior urethritis with slight secretion the 
first urination zvould be cloudy and the second practically 
clear, as in anterior urethritis ; but in clironic inflammation 
of the prostate and of the prostatic urethra the mucous shreds 
are usually long and stringy, while those from the anterior 
urethra are smaller and finer. In chronic inflammation of 
the prostate the urine, with the exception of the flocculi, 
will usually be clear. 

Of course, there are no hard-and-fast rules, but an exam- 
ination of the urine is generally of assistance in determining 
the part involved. 

Epididymitis. — The epididymes consist of a large upper 
part, called the globus major, and a small lower part, the 
globus minor, the two being connected by the body. The 
globus major is composed of efferent ducts which con- 
vey the spermatozoa from the testis to the globus minor, 
where the vas deferens begins, and by means of which 
the secretion is carried to the seminal vesicles. 

After gonorrhea has lasted for three or four weeks, invading 
the deeper portion of the urethra, the patient may complain 
14 



1 62 VENEREAL DISEASES. 

of uneasiness and pain in the testicles, which upon examina- 
tion are found to be enlarged and tender. Although the 
name of orchitis has been given to this affection, the body 
of the testicle itself is not implicated, but only the epididymis, 
which in this stage of the disease is attended by the usual 
symptoms of pain, redness, and swelling. You remember, 
when we were discussing syphilis, I mentioned a form of 
epididymitis which occurs in that disease, and I wish to 
call your attention to the diagnostic points of difference 
which obtain between the two varieties. /;/ syphilitic epi- 
didymitis this body is indurated, but is devoid of pain or red- 
ness ; indeed, so little uneasiness is there that the part can 
be freely handled without inconvenience to the patient ; but 
in the gonorrheal variety the epididymis is red, swollen, and 
exquisitely tender ; so much so that the mere contact of the 
bedclothes is sufficient to excite pain and discomfort, and I 
need hardly add that free handling of the part is impossible. 
This affection generally comes on about the third or fourth 
week of the duration of the clap, and during its continuance 
the urethral discharge almost entirely disappears, to reappear, 
however, upon its subsidence. 

The acute inflammation lasts from seven to ten days, at 
the expiration of which time it gradually subsides, leaving 
the epididymis indurated, although not very sensitive, and 
this induration may be further complicated by the effusion 
of fluid between the two layers of the tunica vaginalis, con- 
stituting what is known as hydrocele. Under proper treat- 
ment the fluid is absorbed, and the swelling of the epididymis 
diminishes ; indeed, under very favorable circumstances it 
may entirely disappear ; but this result is not always attained. 
Only too often the epididymis, as zuell as the vas deferens, is 
permanently blocked up, preventing the egress of the sperma- 
tozoa from the affected testis, and leading to partial sterility. 



COMPLICATIONS WHICH OCCUR IN GONORRHEA. 1 63 

Instead of resolution, one other course may be pursued : the 
part may suppurate ; and when it does, destruction of the epi- 
didymis, and sometimes of the testicle on that side, follows. 

The disease is usually unilateral, one testis being affected 
pretty nearly as often as the other ; but sometimes it is 
double, when, of course, it becomes more serious, inasmuch 
as the induration and obliteration of the canals of the vasa 
deferentia lead to permanent sterility. I beg you will dis- 
tinctly understand the difference between sterility and impo- 
tence : the sterile patient is not rendered impotent — he is 
capable of perfect connection even to the emission, but the 
semen ejected is devoid of spermatozoa — in other words, he 
is incapable of procreation ; while the impotent man is 
incapable of connection, although his semen is fruitful. When 
one testis only is affected, the patient can still be the father of 
children, but only as regards his sound testicle. 

The inflammation may extend from the testis to the 
spermatic cord, and when this is the case, the patient com- 
plains of pain running from the testis to the lumbar region, 
with a dragging se?tsatio7i upon the cord, as though traction 
were being exercised upon it. An examination reveals a 
thickened condition of this portion of the genital apparatus, 
which is sometimes enlarged to the size of a goose-quill, 
and excessive tenderness, with inflammatory redness extending 
up as far as the ring. Treatment usually causes these acute 
symptoms to abate in ixova five to ten days ; the tliickening, 
however, lasts longer, until finally it entirely disappears, and 
the cord resumes its normal condition. 

In rare instances resolution does not take place, but instead 
of this suppuration occurs somewhere along the course of the 
cord external to the ring. When this takes place there is 
danger of atrophy of 'the testis, resulting from obliteration of 
the spermatic vessels. 



164 VENEREAL DISEASES. 

Seminal Vesiculitis. — The seminal vesicles, two in num- 
ber, are pyramidal shaped pouches situated one on either 
side between the base of the bladder and the rectum. They 
are a little more than two inches in length and a quarter 
of an inch in breadth. They serve as reservoirs for the 
fluid secreted by the testes, and also secrete a fluid acces- 
sory to that of the testes. Each is a tube, but so con- 
voluted that it is like a little sacculated bladder. The 
vesicles are shaped something- like the letter V, with their 
broad ends diverging backward from the base of the bladder, 
and their narrow ends, which come nearly in contact with 
each other, converging as they are joined by the vasa defer- 
entia, which at this point lie on their inner sides. After the 
junction of each seminal vesicle with the corresponding 
duct of the vas deferens the two continue to form the ejacu- 
latory duct. This duct, one for each side, is about three- 
quarters of an inch long and ends in a slit opening into the 
lower portion of the prostatic urethra. 

The vasa deferentia are enlarged at their upper ends, 
forming the ampulla of Henle, to unite on each side with 
the corresponding seminal vesicle. They convey the secre- 
tion of the testes from the lower portion of the epididymes 
to the corresponding seminal vesicle. 

The gonococais is the cause of the majority of diseases of 
the seminal vesicles. Other micro-organisms occasionally 
act as causative factors in affections of these organs, and in 
some patients a simple or a gonorrheal inflammation of the 
vesicles is followed by tuberculosis. The gonorrheal infection 
may be twofold : direct or indirect. In direct infection the 
gonococci may be forced into the ejaculatory ducts by im- 
proper methods of treatment, such as violent forms of 
irrigation, the unskilful use of instruments, etc., and, in 
some few instances, they may directly invade these ducts 



COMPLICATIONS WHICH OCCUR IN GONORRHEA. 1 6$ 

without any apparent exciting cause. In indirect infection 
we have an inflammation of the deep urethra which gradu- 
ally involves the mouths of the ejaculatory ducts, and thus 
extends into the seminal sacs, when it becomes chronic and 
resistant to treatment. 

In certain urethral discharges which go under the name 
of chronic gonorrhea or gleet, a pathological condition of 
the seminal vesicles is the cause of the secretion, and until the 
disease in the seminal sac is removed by treatment, the case 
remains incurable. 

In health the seminal sacs are felt by rectal examination 
as soft, smooth bodies freely movable under the finger, and 
not specially sensitive, but in disease they are usually quite 
tender and are frequently much enlarged. 

At first manipulation will express but little of their con- 
tents, which should be repeatedly examined under the 
microscope, as in this way we can follow the progress of 
the case. The spermatozoa at first appear macerated and 
motionless, but later on, as the case improves, more secretion 
is expressed from the vesicles and the spermatozoa gradu- 
ally present normal formation and action. 

The condition just described is one where the seminal 
vesicle alone is involved. When, on the other hand, the 
inflammation extends outside of the seminal sac and there 
is a perivesicular inflammation, we have a much more serious 
condition to deal with. This perivesicular thickening and 
inflammation may be so marked that the outlines of the vesicle 
are lost, the region between the. bladder and rectum becomes 
involved in the inflammatory exudation, and the seminal 
vesicle is bound down and immovable. 

This infiltration of the surrounding parts may extend into 
the capsule of the prostate, which condition is commonly 
mistaken for a true involvement of this o reran. The inflam- 



1 66 VENEREAL DISEASES. 

mation just described is of a low grade, and until recently 
has received but little attention. 

Tuberculosis of the seminal vesicles will usually, upon 
rectal examination, impart a nodular feeling to the finger, 
and rectal manipulation will be followed by considerable 
pain and an inci'ease of the symptoms generally. 

Cystitis. — Cystitis has occurred from the invasion of the 
normal vesical mucous membrane by the gonococcus, but 
such a condition is so rare that its treatment need not be 
considered here. 

When cystitis follows a gonorrhea of the urethra, it is 
usually the result of a mixed infection, the bacillus coli com- 
munis, the streptococcus, or the staphylococcus, and not the 
gonococcus, being the cause of the cystic inflammation ; in- 
deed, evidence shows that the gonococcus, ivhen not com- 
bined with other bacteria or with a previous abnormal con- 
dition of the ge nit o -urinary tract, is a rare cause of cystitis. 

Invasion of the ureters and kidneys by the gonococcus 
has also occurred, but rarely. It is usually associated with 
other pathological conditions, such as urethral stricture, 
mixed bacterial infection, or some abnormal state of the 
urinary tract, hence I shall merely mention the fact that 
such a complication may result from a primary invasion of 
the urethra by the gonococcus. 

Stricture. — The urethra in the average adult male is 
about eight inches long. It is divided into the penile urethra, 
about six inches long ; the membranous urethra, three- 
fourths of an inch long ; and the prostatic urethra, about 
I y^ inches in length. 

When examining the urethra with instruments, it is well 
to remember that this canal is not of uniform calibre through- 
out, but varies very much in its different parts. 

At the meatus and membranous urethra the canal is 



COMPLICATIONS WHICH OCCUR IN GONORRHEA. 1 67 

smallest, so that variations in size of the normal urethra 
must not mislead us into the belief that we are necessarily 
dealing with stricture. 

Spasm of the urethra, sometimes caused by the introduc- 
tion of a small, pointed instrument in ignorant hands, may 
simulate a true stricture in sensitive persons. 

Urethral stricture is of slozv formation and is a not un- 
common result of chronic gonorrhea. 

Toward the end of a clap, when the discharge has become 
thin and colorless ; when the anterior portion has entirely 
recovered its normal condition while the posterior portion 
of the urethra still remains diseased, a condition of affairs 
arises known as chronic gonorrhea. Here the discharge, 
instead of being continuous, as during a clap, is only 
seen on rising in the morning as a single drop of white or 
colorless matter, which does not stain the linen, and which 
is not accompanied with any pain during micturition. This 
drop of fluid is usually obtained only upon deep pressure and 
during the day is absent. If the patient commit any excess 
in eating or drinking or if he indulge in immoderate coitus, 
this drop may increase to a slightly purulent discharge, which 
lasts for a few days, and then subsides to its former condi- 
tion. Examination with a bulbous bougie may reveal in the 
membranous or prostatic portions of the urethra one or more 
localized points of tenderness, which offer a slight resistance 
to the passage of the bougie, and which usually bleed. This 
is due either to a granular and thickened condition of the 
urethra, the incipient stage of stricture, or else to a slight 
stricture which has already formed. 

Remember, therefore, that some cases of chronic urethral 
discharge are dependent upon stricture ; hence when called 
upon to treat a persistent discharge, first examine the urethra 
and, failing to find anything abnormal in the canal, examine 



1 68 VENEREAL DISEASES. 

for disease of the seminal vesicles. If we find no disease of 
the seminal vesicles nor any evidence of stricture, the dis- 
charge is probably due to inflammation of the deep urethra, 
attended, perhaps, with slight granulations of the mucous 
membrane, which will require different treatment from what 
we would use if dealing with stricture. Urethral stricture 
and disease of the seminal vesicles may occur in the same 
patient. This combination, however, is not .common. 

I have purposely omitted speaking at length on stricture, 
as this form of disease belongs more properly to the domain 
of genito-urinary surgery than to venereal medicine ; and I 
only mention it here to show you how it may act as one of 
the underlying causes of chronic gonorrhea. 

Lymphangitis and Adenitis. — If the inflammation be 
very acute, the lymphatics and the inguinal glands in both 
sexes are implicated. In the male the lymphatics running 
along the dorsum of the penis may be felt as a hard line, the 
size of a large goose-quill, extending from the fossa glandis 
to the crura penis, and are there lost in the inguinal chain of 
glands. Their course may often be followed by the eye, ap- 
pearing as a broad, red line overlying the inflamed lymphatics. 
After a while the inflammation subsides, and the lymphatics 
are no longer apparent to the eye or to the finger, or else 
suppuration occurs at one or more points along their track, 
which, upon evacuation of the pus, usually heal readily. 

This inflammation may extend to the inguinal glands, 
when we have in one or both groins a tense, braiuny, and 
inflamed szuelling, painful to the touch and a hindrance to 
locomotion. This enlargement may be ushered in with a 
chill and a slight elevation in temperature. Sometimes 
the inflammation subsides without ending in siippuration, 
while at other times pus forms within the body of the 
gland and an abscess is the result. 



COMPLICATIONS WHICH OCCUR IN GONORRHEA. 1 69 

Gonorrheal rheumatism, when it appears, generally 
comes toward the end of a clap, — although there are ex- 
ceptions to this rule, — and invades joints in preference to 
other parts — usually the knee, the elbow, and the wrist. 
Occasionally very acute and attended with a marked degree 
of inflammation, its general course is a subacute one, with 
swelling and pain. Shortly after the access of the disease 
effusion of fluid takes place into the joint, accompanied with 
an increase of pain ; continuing in this condition for a time 
Varying from two weeks to several months the fluid is grad- 
ually absorbed, and the joint may be restored to its former 
usefulness. Unfortunately, however, this is not always 
the case ; ligamentous adhesion takes place, and anchylosis, 
partial or complete, is the final result. I know of no cases 
in the entire range of venereal affections more dishearten- 
ing and annoying than those of gonorrheal rheumatism, 
both on account of their chronic course and because the re- 
sults of treatment are but too often unsatisfactory. 

Next to the joints in point of frequency of attack the ten- 
dons come, and then the muscles. Of the former, the tendo 
Achillis is the one most likely to suffer, and when it is at- 
tacked, the disease runs a long and painful course, not so 
much from the swelling, for this is often trifling, as from the 
steady aching of the part and the consequent impediment to 
walking. In very severe cases a permanent contraction of 
this tendon results, producing a talipes equinus, for which 
tenotomy is the only relief. 

Another peculiar symptom occasionally met with in this 
stage of gonorrhea is a persistent, boring pain in the os 
calcis, unattended by redness or any enlargement of the 
bone or thickening of the periosteum, which is chronic in 
its course, and very apt to occur in nervous men. I recall 
one case where it had lasted for several years. Indeed, 



I70 VENEREAL DISEASES. 

I am inclined to regard it as a neurosis rather than a perios- 
titis. 

Until within a few years it was believed that the heart 
was not implicated in gonorrheal rheumatism, differing in 
this respect from the ordinary form of rheumatism. This is, 
however, a fallacy ; the pericardial sac as well as the valves 
of the heart are affected. The patient complains of pre- 
cordial pain, attended sometimes with dyspnea, when an 
examination reveals an effusion into the pericardium, and the 
hearts oimds are muffled. As this subsides a souffle is heard 
at the aortic and mitral valves, sometimes with regurgitation. 

Gonorrheal ophthalmia has been divided in many treat- 
ises on venereal diseases into two varieties : one due to the 
presence of gonorrJieal pus in the eye ; the other, analogous 
to what take place in gout, an iridoscleritis rather than a 
true ophthalmia. The latter is the only bona-fide disease 
which belongs to gonorrhea, the first one, although by far 
the more serious, is nothing more than a purulent ophthal- 
mia due to an accidental infection. 

The first symptom of which the patient complains is a 
sensation of zveakness in the eye ; this is very seldom associ- 
ated with plwtophobia, although occasionally it may also be 
present. Upon examination the conjunctival and sclerotic 
vessels will be found somewhat congested, the iris slightly 
infiltrated, with a sluggish pupil, the anterior chamber dis- 
tended with fiuid, containing occasionally some flocculi. The 
tension of the eyeball is also increased. As the disease pro- 
gresses the anterior capsule of the lens, as well as Descemet's 
membrane, becomes opaque, and the cornea loses its trans- 
parent look. 

This condition lasts for some days, when, under proper 
treatment, the symptoms subside ; the iris, the capsule of 
the lens, and the cornea resume their normal appearance, 



COMPLICATIONS WHICH OCCUR" IN GONORRHEA. I/I 

and the disease passes off, leaving the eye none the worse 
for the attack. 

Not so, however, with the purulent variety. Here the 
situation is very grave, and unless active measures are 
speedily adopted the eye is irretrievably injured, the contents 
of the globe being evacuated in forty-eight hours or even in less 
time. This disease is due to conveyal of the pus from the 
genitals to the eye, and the right is the one most frequently 
affected. The symptoms noticed are lachrymation, photo- 
pliobia, intense congestion of the conjunctival vessels, together 
with a thick, purulent discharge. Both lids speedily become 
edematous and enormously swollen ; so much so as to close 
the eye completely. If the lids be gently separated, the 
conjunctival and palpebral mucous membranes will be found 
szaolleu and perfectly scarlet in lute. The former, from the 
swelling, is very much elevated above the cornea, leaving 
this latter embedded in the inflamed tissue, like a watch- 
glass in its setting. This swelling is known as chemosis. 

The cornea, curiously enough, is at first unaffected, but 
from pressure and interference with its nutrition it rapidly 
becomes opaque, pus forms in the interstitial layer, which, 
pushing through the epithelial covering, leaves behind 
ulcerations of the cornea ; this tissue softens, and the tension 
of the eyeball being great, the lens and vitreous humor are 
evacuated through the opening ; in other words, the eye is 
completely lost. 

While this is going on an abundant purulent secretion is 
poured out over the cheeks, producing excoriation of the 
skin of these parts. Occasionally the pressure from the 
edema upon the lids is so great that gangrene ensues, 
sloughing of the lids occurs, and greater or less deformity 
follows. 

Under prompt treatment, thoroughly carried out, the eye 



172 VENEREAL DISEASES. 

may be saved ; but opacity, with some ulceration of the cor- 
nea, nearly always results. The edema subsides, the che- 
mosis disappears, and the conjunctival congestion abates in 
intensity. A thickened and granular condition of the pal- 
pebral mucous membrane remains, however, for a long- 
time after, which requires steady and constant care to cure. 
Warts. — In addition to the above-mentioned complica- 
tions which occur in the course of a clap, there is one dis- 
ease, commonly known as venereal warts, which, although 
not strictly a complication, is frequently found with gonor- 
rhea or else as an indirect result. The term vene- 
real warts is another one of those misnomers which abound 
in the literature of venereal diseases ; for although sometimes 
found with a gonorrhea, they may be absolutely and entirely 
independent. They are usually seated, in the male, upon 
the mucous membrane of the glans penis, the inner lamella 
of the prepuce, upon the scrotum, and sometimes upon the 
perineum and the pourtour of the anus ; in the female, upon 
the mucous membrane of the labia majora et ndnora, upon 
the perineum, and about the anus. They occur as papillary 
excrescences, raised above the surface of the mucous mem- 
brane, exceedingly vascular, briglit red in color, and, when 
favored by heat and moisture, are of exuberant growth. 
They are, indeed, nothing but hypertrophy of the natural 
papillae of the parts, and are particularly prone to attack 
those who are careless of their personal cleanliness. They 
may attain to enormous size, and I have seen cases where 
the head of the penis was transformed into a huge bidbous 
mass, resembling a cauliflower, entirely obliterating all 
semblance of the ordinary virile member. Their shape 
varies somewhat with their location, and when they are 
compressed, — as, for example, when seated on the perineum 
or in the cleft of the nates, — they grow in the shape of a 



COMPLICATIONS WHICH OCCUR IN GONORRHEA. 1 73 

cockscomb, being long, pointed, and serrated. In the female 
we find them most exuberant, and they sometimes extend 
from the anus over the perineum and vulva, up even into 
the groins, assuming the most grotesque appearances, and 
from attrition and dirt give rise to a very offensive and acrid 
discharge. 

Herpes, although not strictly venereal in its origin, is 
another manifestation which it behooves you to know some- 
thing about, inasmuch as it is frequently confounded with 
superficial chancroids or mucous patches of the glans 
penis. It appears upon the mucous membrane of the pre- 
puce and glans penis as a grotcp of minute vesicles, five or 
six in number, seated tipon a slightly inflamed base. These 
vesicles rapidly coalesce, and in the course of twenty -four 
to thirty -six hours are denuded of their epithelium, when they 
present superficial erosions, which are sometimes covered 
with a whitish pellicle. If seen early in their course, before 
the vesicles are broken, there will be no difficulty in recog- 
nizing the disease ; but when the vesicles have become 
eroded, it is sometimes extremely difficult to distinguish 
them from superficial chancroids and mucous patches. The 
nonauto-inocidability of herpes, the rapidity with which it re- 
covers ww&zr simple treatment, its nontendency to spread, and 
its history, will serve in most cases to prevent you from mis- 
taking it for the first ; and the absence of all syphilitic history 
and concomitant symptoms of the pox will save you from mis- 
taking it for the second class of these diseases. It is some- 
times due to local causes of irritation, but is quite frequently 
associated with nervous and digestive disturbances induced 
by overindulgence in eating and drinking and by mental 
excitement. 

Gonorrheal complications in the female involve the cervix 
uteri and, by extension, the uterine cavity, the Fallopian tubes, 



174 VENEREAL DISEASES. 

the ovaries, and, occasionally, the peritoneum, all of which 
may be attacked. 

Cervicitis and endometritis may occur at any time in 
the course of a gonorrhea and are always serious. This 
inflammation of the neck and body of the uterus commences 
with a feeling of congestion in the region, attended by severe 
bearing-down pain and disturbance of the menstruation, which 
is usually scanty and difficult, and is accompanied with a dis- 
charge from the cervix, at first mucopurulent and then en- 
tirely purulent. If a rectovaginal examination be made the 
uterus will be found sivollen and tender, and pressure above 
the pubes excites pain attended with increase of temperature, 
a full pulse, and general constitutional disturbance. The 
inflammatory process usually involves the entire uterine 
cavity and, as already stated, may extend to the Fallopian 
tubes, the ovaries, and the peritoneum. 



CHAPTER XII. 

TREATMENT OF GONORRHEA AND ITS 
COMPLICATIONS. 

Of all venereal diseases which require treatment at the 
hands of the surgeon gonorrhea is the most uncertain 
and disagreeable. The number of nostrums sold and the 
various methods of treatment employed to cure a clap are 
innumerable, which only goes to prove that the infallible 
and rapid cure-all for gonorrhea so frequently written about 
has not yet appeared and probably never will. 

Before taking up the various steps in the treatment of 
gonorrhea it is well to remind you that this inflammation 
has something of a self-limited course, and our object should 
be, first, to promote the comfort of the patient ; second, to 
ensure the elimination of the gonococcus, and third, to avoid 
complications. The so-called abortive treatment is not at all 
advisable as a routine method, and yon had better leave it 
alone, although in certain selected cases, in the hands of a 
skilled specialist, a case may be cured in a few days from 
the time of onset. This treatment must be used on the 
appearance of the first local signs, otherwise it is of little 
avail, the patient being frequently seen by his medical 
adviser, so that any unfavorable symptom may be at once 
detected. The most radical form of abortive treatment is 
that in which the surface of the urethra is wiped thoroughly 
dry through the endoscope with absorbent cotton, first 
washing out the canal with a solution of dioxid of hydrogen 
(10 to 15 volumes), and then applying a 5 to 10 per cent. 

i75 



I76 VENEREAL DISEASES. 

solution of silver nitrate on a cotton tampon to the urethra 
for half an inch beyond the diseased area. If necessary, 
this may be repeated in forty-eight hours. 

Another method, much milder and which is frequently 
successful, is to wash out the anterior portion of the urethra 
with hot water ; then, with the aid of an Ultzmann's syringe 
introduced to within an inch of the bulbus urethral, to inject 
the medicated solution gradually into the canal, at the same 
time gradually withdrawing the instrument. Protargol, ar- 
gentamin, and argonin in 5 to 10 per cent, solutions have 
been successfully used in this way. After the first solution 
has been introduced in the manner just described and kept 
in the urethra from five to ten minutes another syringeful 
is injected in the same way, but is not carried so far into the 
canal. The first few injections will indicate if this latter 
method is likely to prove successful. The second pro- 
cedure is not so radical as the first one, nor is it usually 
attended with danger. The treatment should be continued 
for fully ten days after all signs of gonorrhea liave disap- 
peared, gradually increasing the interval between each in- 
jection. 

The object of both of these methods is rapidly to elimi- 
nate the gonococci before they have burrowed deeply under 
the surface of the urethra. 

In treating inflammations of the urethra it is well to re- 
member that we are dealing with a dual symptom, a very 
sensitive and easily infected genital apparatus connected 
with the urinary one. Were this not the case, the treat- 
ment of gonorrhea would be much simpler ; hence it is of 
importance to exercise due care and persistence in the use 
of medications, which are of two-fold application : the one, 
continuous, — viz., recurrent irrigations, — the other, inter- 
mittent, — i. e., syringing. Thus if the attack be an acute 



TREATMENT OF GONORRHEA AND ITS COMPLICATIONS. IJJ 

one, no local medication or interference is admissible. Don't 
meddle with things yon ought to leave alone ; but so soon as 
the acute symptoms have subsided, you may and should 
institute local treatment, and then the quicker you do so 
the better are the chances of recovery for your patient. 

Part of this local treatment you can relegate to the patient 
and part you should keep in your own hands. / do not 
believe it good policy to allow the patient to use recurrent 
irrigations himself. In my experience he is as apt to do 
harm as good ; because the hydrostatic pressure employed 
may be too great and he may force the injection too rapidly 
and with too great power, thus injuring the urethra. You 
may, hozvever, leave the injection by syringe in his hands. 
There, unless he intends injury, he can do no harm to him- 
self under proper guidance by the surgeon. I do not 
believe that a careful and well-instructed surgeon will ever 
do his patient harm by the recurrent irrigations, either by 
direct injury to the urethra, by forcing the gonococcus back- 
ward, or by breaking down the resistant power of the con- 
strictor Jircthra? muscle. If he does the first and the last, 
he is unfit to practise ; and as for the danger attending the 
second manoeuvre, I believe it to be absolutely nil. The gono- 
coccus is a tenacious microbe, and not easily swept from 
its abiding-place ; moreover, when it is detached, — and 
this is what your treatment aims at, — it is swept away from 
and 07tt of the urethra by the recurrent flow, not forced back 
into the deeper parts of the canal ; and if the injection be 
medicated with a germicide, such as the bichlorid of mercury, 
you have taken all prudent measures to ensure the destruc- 
tion of the gonococcus. 

Sometimes this form of medication is highly successful, 
particularly if used as early as the inflammatory conditions 
will allow ; but I frankly admit that I consider it only an 
i5 



I78 VENEREAL DISEASES. 

adjuvant and it can not be considered as the mainstay in 
the treatment. 

The various medicated solutions to the anterior and pos- 
terior urethra are of great service, and are the best methods 
of treating gonorrhea. The manner of using them will be 
considered later on. 

The internal use of drugs to assist in the cure of the case 
is of minor importance, much less so than the local treatment. 

Although gonorrhea is considered a local disease, con- 
stitutional symptoms are not very uncommon, and some- 
times, though rarely, a case may present symptoms of gon- 
orrheal septicemia. 

Remember, t/ien, that besides treating the local condition 
in the urethra we must be on the watch for complications in 
remote parts. 

Whenever possible, insist that the patient secure absolute 
rest in bed during the acute onset of the disease, because the 
course of the disease would be much less painfid, would have 
fewer complications and a shorter duration, if all patients 
could be kept in bed for the first ten days of a clap. Un- 
fortunately, most patients, for obvious reasons, decline to 
follow such advice. Failing that, the patient should be 
instructed to keep as quiet as possible, his bowels should be 
carefully regulated, and precise directions be given as to his 
diet and mode of life. All sexual excitement must be care- 
fully avoided, and alcohol in any form should be strictly for- 
bidden. A warm sitz-bath at bedtime during the acute stage 
often has a sootlung effect and promotes sleep. 

During the acute inflammatory stage, when febrile symp- 
toms are present, when the penis is hot, inflamed, and 
edematous, when the mucous membrane of the parts is con- 
gested and there is eversion of the lips of the meatus with a 
scanty mucous or mucopurulent discharge, your first object 



TREATMENT OF GONORRHEA AND ITS COMPLICATIONS. I 79 

should be to relieve these symptoms, and the use of injec- 
tions in this stage is entirely inadmissible. For the relief 
of the febrile symptoms I know of nothing which will take 
the place of aconite, in small doses frequently repeated, thus : 

R. Tinct. aconit. radic, '"ij-ij- 

SlG. — In a little water every hour. 

To relieve the edema and swelling of the penis use cold- 
water dressings, or wrap the organ up in cloth wet with the 
lead-and- opium wash, which is administered as follows : 

r£ . Liq. plumb, subacetat, 

Tinct. opii, aa^j 

M. Aquae, q. s. ad^viij. 

SlG. — Locally. 

These symptoms usually disappear in the course of 
forty-eight to seventy-two hours, when the discharge be- 
comes purulent, abundant, and associated with a frequent 
desire to pass water, not from any invasion of the neck of 
the bladder, but simply from reflex action due to local irrita- 
tion within the first inch of the urethra. 

The diet during this stage should be of the lightest, such 
as milk, milk porridge, gruel, and the farinaceous articles 
of food. 

Now is the time to begin with injections. Antiseptic prep- 
arations are best in the earlier, and simple astringents in the 
declining, stage of the disease. All kinds of urethral irriga- 
tion should be used hot, as they act more effectively. Two 
methods of irrigating the anterior urethra are employed : 
one is to use a large quantity of hot solution, perhaps a 
quart or more at a time. This plan is excellent, but some- 
what complicated, and for various reasons many patients 
can not use it. The solution, properly prepared, is placed 
in a receptacle, as a fountain syringe, suspended two or 
three feet above the patient's head, the man lying on his 



l8o VENEREAL DISEASES. 

back ; by the aid of a blunt glass nozzle introduced just 
within the meatus the anterior urethra may thus be thor- 
oughly washed out. This nozzle should have an inlet 
and an outlet, so as to maintain a continuous flow until the 
entire amount of the solution has passed in and washed out 
the area of the diseased urethra. This requires time and a 
special apparatus, and care must be exercised not to do 
harm to the deeper parts from overpressure. This irriga- 
tion should be made twice a day. In place of the glass 
nozzle a soft-rubber catheter introduced two or three inches 
into the urethra may be used, as being more easily managed. 

The other method of washing out the anterior urethra is 
by the aid of the time-honored hand syringe, and is the most 
available and simple way for the majority of patients. 

In using these injections there are some points to which 
I wish to call your attention, for upon the proper employ- 
ment of this class of remedies will often depend the efficacy 
of the treatment. In the first place, never use a glass 
syringe if you can help it, as the fluid nearly always comes 
out behind the piston instead of through the nozzle, and the 
patient receives very little of the injection. The syringes 
made of vulcanized rubber are the best, but even some of 
these are objectionable, from their long, sharp nozzles. All 
urethral syringes used during the early stages of clap should 
have a short, blunt, or conical point, which, when introduced 
into the meatus by gentle pressure and the aid of the 
fingers, prevents any of the injected fluid from escaping. 

Another very serviceable form of syringe is a soft-rubber 
bulb with a blunt point. This syringe, which should hold 
about six drachms, obviates all trouble with a piston, the 
contents being expelled by gentle pressure of the bulb ; it 
is easily kept clean and can not get out of order. But what- 
ever syringe is used, whether a vulcanized rubber piston one 



TREATMENT OF GONORRHEA AND ITS COMPLICATIONS. I 8 I 

or one with a rubber bulb, it should hold at least four 
drachms of fluid. The little pocket syringes which are sold 
in many shops are catch-penny affairs. 

The patient having chosen a proper syringe, should be 
advised as to the right way to make an urethral injection. 
As has already been said, in most cases some antiseptic prep- 
aration should be employed in the early stage of the disease 
after the very acute symptoms have subsided. Corrosive 
sublimate, I : 10,000, permanganate of potash, 1 : 5000, 
nitrate of silver, 1 : 6000, and argonin in 5 to 10 per cent, 
solutions are perhaps the best ; and they act by causing the 
destruction of the gonococci with which they come in con- 
tact. The patient may be directed to make a stock solution 
of the particular antiseptic ordered, which can then be 
diluted with hot water to the desired strength. These drugs 
also have a secondary astringent effect, and when used in 
the strength advised, are very efficient. To derive the most 
benefit from injections it is important that the patient should 
be instructed by the surgeon in the use of the syringe. The 
man should first urinate, in order to wash out as much as 
possible of the discharge, but if he can not, it is well to 
allow the first syringeful to flow immediately out of the 
urethra, so as to cleanse the canal thoroughly. 

The syringe having been carefully charged with the 
solution and all air excluded from the barrel, the patient is 
then ready to take his injection, which he does in the fol- 
lowing manner : He holds the instrument in his right hand, 
between the thumb and second finger, the index-finger being 
stationed at the butt end of the piston. The penis is held 
between the second and third fingers of the left hand, 
palm upward, the index-finger and thumb being left free 
to separate the lips of the urethra. The nozzle of the 
syringe is then carefully inserted just within the meatus, 



152 VENEREAL DISEASES. 

when the end of the urethra is closed against the instrument 
by a gentle lateral pressure. Do not place the finger and 
thumb above and below the meatus, otherwise you will open 
the canal instead of closing it, and the fluid will escape as 
fast as it is injected ; but make a gentle pressure sideways, 
and if this be properly done, none of the fluid will run out. 
Now. with the right hand gently drive the piston home, 
without any sudden movement, and if the syringe is in 
proper working order, this can be readily accomplished. 
This done and all the fluid deposited within the urethra, 
with a quick movement withdraw the nozzle of the syringe 
from the urethra with the right hand, while with the thumb 
and index-finger of the left hand still in position the patient 
closes the meatus. This prevents the outflow of the injec- 
tion. Then, laying the syringe down, the patient with his 
right hand gently strokes the floor of the urethra from 
behind forward in order to press the fluid as far as possible 
into the anterior portion of the canal, which is the seat of 
the disease in the earlier stage. As the disease invades 
deeper parts this motion must be reversed in order to crowd 
the fluid backward. After the injection has been retained 
from five to ten minutes, the compression with the left hand 
upon the lips of the meatus may be discontinued, when a 
portion of the fluid will run out. The injection should 
cause a slight sensation of warmth and tingling in the canal 
for five or ten minutes after its use, but this should never 
amount to actual pain ; if such be the case, it shows that 
the injection is too strong and must be diluted. 

Within a few years a method of treating gonorrhea by 
means of medicated bougies has been advocated. The}' are 
made of cacao-butter, holding an astringent in minute sub- 
division, and are left within the urethra to melt. Experi- 
ence has not shown me that they have any special advan- 



TREATMENT OF GONORRHEA AND ITS COMPLICATIONS. I 83 

tage over injections, and they have the decided disadvantage 
of being dirty and disagreeable. 

When the discharge has very perceptibly diminished, 
from the subsidence of the acute symptoms, when, in fact, 
the disease is in the declining stage, simple astringent in- 
jections are very efficacious ; among these the preparations 
of zinc are the most useful. 

As the gonorrhea goes on to recovery the gonococci 
diminish in number, but the urethra is usually congested, as 
a result of the inflammatory process ; simple astringents 
give the most satisfactory results in this stage. Of course, 
no hard-and-fast rule can be laid down as to the time 
of using antiseptic and astringent injections. In some 
cases of gonorrhea the urethra will not tolerate antiseptics in 
the acute stage of the disease without causing severe pain, 
and in such cases astringent solutions must be substituted, to 
be continued, if necessary, throughout the entire treatment. 
The following prescriptions have been found of most service. 
Of course, we may prescribe these preparations in powder 
mixed with some bland ingredient, so made up that a tea- 
spoonful of the powder dissolved in a given amount of warm 
water will furnish the required strength. 

&. Zinc, sulph., gr. viij-xij 

Aquae, ^iv. 

M. 

Sig. — To be injected thrice daily. 

Or— 

R . Zinc. acet. , gr. viij-xij 

Aquae, ^i v « 

M. 

Sig. — Inject thrice daily. 

Alum, either alone or in combination with tannin, as well 
as tannin alone, have been advised as injections, but in my 



184 VENEREAL DISEASES. 

estimation they possess no advantages over the preparations 
of zinc. They may be used as follows : 

R. Alumin. sulph., . gr. xx 

Aquae, ^iv. 

M. 

SiG. — As injection thrice daily. 

R . Alumin. sulph., 

Acid, tannic, pulv., . . aa gr. x-xv 

Aquae, ' . . . ^ iv. 

M. 

To be well shaken before using. 

SiG. — Inject thrice daily. 

One of the objections to the use of tannin is the persistent 
stain which it leaves upon the body-linen, but I shall shortly 
mention a simple way of obviating this. 

An injection — a modification of Ricord's formula — is 
often used, and is an excellent one. It is composed of the 
following ingredients : 

R. Zinc, sulph., gr. viij 

Plumb, acet., gr. xv 

Tinct. opii, 

Tinct. catechu comp., aa^ij 

Aquae, ad ^ iv. 

M. 

SiG. — As injection thrice daily. 

To obviate the staining of the clothes, either from the 
disease or from the injections used, a false front may be 
made by pinning to the skirt a double fold of unbleached 
cotton the size of the front flap. It also has the advantage 
of keeping the genitals clean and cool. Never countenance 
zvrapping up the penis in innumerable folds of linen or cotton, 
which is so often done, as this keeps the parts in a heated 
condition, prevents the free exit of the pus which forms in 
the urethra and which, from the irritation of its presence, is 
very prone to produce balanitis and edema of the prepuce. 



TREATMENT OF GONORRHEA AND ITS COMPLICATIONS. I 85 

Internal medication may be used with the local treatment, 
and consists of those remedies which are excreted by the 
kidneys and which contain a balsam or resin : foremost 
among these are copaiba, cubebs, and the oil of yellow 
sandalwood. In order to cover their nauseating taste they 
are given either in pill form or in capsule, in the following 
manner : 

R. Copaike, ^j 

Oleoresin. cubebse, . ^ss 

Magnesiae, " q. s. 

Ut ft. massa. Divide into pills of five grains each. 

Sig. — Three to six three times daily after meals. 

If given in capsule, the balsam of copaiba, the oil of 
cubebs, or the oil of sandalwood is employed, each capsule 
being supposed to hold ten minims of these various drugs. 
Of them all, I can particularly commend the oil of the 
yellow sandalwood. Two objections may be urged against 
it : first, the difficulty of getting it pure ; and second, its 
expense. If, from either of these two causes, it should not 
be given, the copaiba is, to my mind, the next best drug, 
given in pill or capsule, as already noted. 

These preparations have the effect of relieving the ardor 
urincu and of checking the discharge. They should always 
be given after meals, as they are then less liable to disturb 
the stomach or to produce nausea. If the patient's stomach 
will bear them, the effect is sometimes wonderful ; but their 
long continuance is liable to produce pain in the region of 
the kidneys and a deposit in the urine which has been mis- 
taken for albumin. 

A very simple, at the same time effective, way of relieving 

the ardor urince is to make the patient pass his urine in a 

vessel nearly full of hot water — in other words, pass his 

water under zvater. 
16 



1 86 VENEREAL DISEASES. 

As regards diet, the rules must be strictly laid down, and 
no deviation allowed until the disease has entirely disap- 
peared. Except during the acute inflammatory stage, the 
patient should not be kept upon a low diet, but ought, on 
the contrary, to be allowed a good and nutritious regimen. 
Meat,, vegetables, fish, eggs, and the like may be allowed, 
and I beg you to remember that by half starving your 
patient you only tend to keep up the gonorrhea. Aspara- 
gus, highly spiced dishes, strong coffee or tea, and, above 
all things, every form of alcoholic or malt beverage, as well 
as immoderate smoking of tobacco, should be interdicted in 
the majority of cases ; but if the patient has been accus- 
tomed to their use, a cup of zveak coffee or tea well diluted 
with milk may be allowed once daily. Lemonade, the 
copious use of mineral zvaters, and cider, should also be 
tabooed, and the patient confined to water or milk as 
drink. Flaxseed-tea has been recommended, but it is 
usually such a nauseous mess that the patient is only too 
glad to drop it out of his list of beverages. In the summer- 
time there is no objection to the use of the ripe fruits, and 
their juice often makes an agreeable addition to water; but 
such drinks should be sparingly sweetened, as a portion of 
the sugar is converted into alcohol in its passage through 
the human system. 

Occasionally toward the close of the acute stage the 
gonorrhea will extend from the anterior into the posterior 
urethra, under which circumstances an exacerbation of the 
symptoms is likely to occur. There is frequent and painful 
urination, with vesical tenesmus, in some cases blood being 
voided with the urine, although blood following urination 
does not necessarily mean involvement of the posterior 
urethra. In posterior urethritis, where the discharge is 
free, the urine collected in two beakers will be equally 



TREATMENT OF GONORRHEA AND ITS COMPLICATIONS. I 87 

cloudy. In combination with these symptoms we usually 
have fever, malaise, and various other constitutional distur- 
bances. All local treatment should be immediately discon- 
tinued, the bowels kept open, and balsamics given by the 
mouth to soothe the genito-urinary tract and render the 
urine bland. When possible, the patient should be induced 
to remain in bed, and all efforts must be exerted to avoid 
complications in the epididymes, seminal vesicles, prostate, 
etc., which frequently follow an attack of posterior ure- 
thritis. 

After a week or ten days, in a favorable case, the acute 
symptoms szibside and the patient is usually left with a 
chronic posterior urethritis. In such cases there is usually 
only a slight discharge, the urine, with the exception of the 
threads, being nearly clear. 

In treating chronic posterior urethritis no anterior irri- 
gations should be used, but after determining that no other 
parts are involved in the disease besides the deep urethra, 
attempts must be made to stimulate the diseased area. 
This can best be accomplished by deep injections with an 
Ultzmann's syringe, or locally through the endoscope. If 
the former be used, nitrate of silver, one grain to the ounce 
of water, may be introduced into the deep urethra every 
four or five days, gradually increasing the strength to five 
grains to the ounce, and is frequently effectual ; sulphate of 
copper may also be used in like manner and in the same 
strength. Stronger solutions (five to thirty grains to the 
ounce of water) of the above-mentioned minerals can be 
used through the endoscope. 

These preparations will usually produce a sensation of 
warmth and a desire to urinate for several hours after such 
treatment, and this is particularly the case when silver nitrate 
is used by the syringe ; more so than when applied through 



I 88 VENEREAL DISEASES. 

the endoscope. In many cases of chronic posterior ure- 
thritis improvement is slow and tedious. 

If the reaction following these deep instillations is too 
pronounced, as shown by fever, vesical tenesmus, etc., de- 
crease the strength of the solution used. In some cases, 
where chronic posterior urethritis exists without compli- 
cations, the introduction of ^fidl-sized, conical steel sound is 
of benefit and should be employed once or^ twice a week. 

The treatment of the complications of gonorrhea in 
men varies according to their character. For balano posthitis 
the most important point to be observed is cleanliness, and 
this, in many cases, will be all that is required. In severe 
cases, upon exposure of the glans penis by retraction of the 
prepuce, the parts may he painted over with a solution of 
7iitrate of silver, from five to ten grains to the ounce of water, 
and the subsequent dressings should be either of ordinary 
starch powder, the impure oxid of zinc (calamin), or lyco- 
podium, and a thin layer of lint or prepared cotton placed 
between the prepuce and glans penis. 

For phimosis, if incomplete, subpreputial injections of 
warm water, or of a slightly carbolized lotion, with proper 
attention to cleanliness, will generally be sufficient ; when it 
is complete, and especially if the foreskin acts as a reser- 
voir for the pus and urine, circumcision should be practised, 
provided the inflammation is not very acute and there be no 
edema. There is no danger in the operation, so far as the 
clap is concerned, for the secretion, you know, is not auto- 
inoculable ; but, of course, be careful that the discharge does 
not come from concealed chancroids instead of gonorrhea. 
Auto-inoadation will here give you the requisite information 
as to its nature. 

Paraphimosis , which is the opposite of phimosis, is relieved 
by compression of the glans penis with the right hand, so 



TREATMENT OF GONORRHEA AND ITS COMPLICATIONS. I 89 

as to squeeze all the blood from the part ; traction forward 
of the prepuce is then made by grasping it posteriorly to 
the constricted portion between the fingers and thumb, 
which are held in the shape of a circle, the penis lying in 
the enclosed space between the fingers. At the same time 
that the forward movement is made the glans is pushed 
backward in the hope of forcing it beneath the constriction. 
If this be not successful, an incision must be made through 
the strictured portion of the foreskin, when the prepuce can 
be drawn forward over the glans, and as soon as the inflam- 
mation and thickening of the foreskin have subsided, the 
unseemly dog's-ears which are left behind may be removed 
by circumcision. 

Chordee, of all complications, is the one that will put you 
to your trumps to relieve. Everything in the pharmacopeia 
has been tried, and, I might almost truthfully say, has always 
been found wanting. Lupulin, camphor, belladonna, opium, 
bromid of potassium, ice, and hot water have all been used 
with varying success ; but to my mind the one remedy 
which gives the most relief is the hypodermic injection of 
morphin and atropin : 

R. Atropiae sulph. , gr. j 

Acidi acetici, q. s. ut ft. solutio cum 

Aqua destil., 2>i y - 

Et adde : 

Morphia solut. (Magendie), q. s. ad unciam unam. 
Of this inject five to eight minims hypodermically. 

This may be given in the perineum or the insides of the 
thighs at bedtime. In injecting into the perineum you must, 
of course, be careful not to wound the membranous urethra 
by carrying the needle too deep ; and if you select the insides 
of the thighs, be careful not to puncture the internal saphen- 
ous vein. All of these dangers may be avoided by making 



190 VENEREAL DISEASES. 

your punctures just beneath the skin. Of the internal admin- 
istration of remedies, camphor and opium, camphor and 
belladonna, or opium and belladomia give the best results, 
thus : 

R . Pulv. opii, gr. j 

Pulv. camph., gr. ij 

Sacch. alb., q. s. 

Ut fiat capsula una. 

SiG. — One at bedtime, and repeat in two hours if necessary. 

R. Extr. belladon. alcohol., gr. ss-j 

Pulv. camph., gr. ij-iv. 

Ut fiat capsula una. 

SiG. — One at bedtime, and repeat if necessary. 

R . Pulv. opii, . . . gr. j — ij 

Extr. belladon. alcohol., gr. ss-j. 

Ut fiat pil. una. 

SiG. — At bedtime, and repeat if necessary. 

The genital organs may also be bathed at bedtime 
in hot water, which will sometimes relieve the tendency 
toward erection, and hot I have found of more service than 
cold applications. A method of immediate relief more gen- 
erally practised among the lower orders abroad than here 
is to place the penis during the state of erection upon a 
table or flat surface and strike it a smart blozu with the fist 
upon its convex surface. This certainly relieves the chordee 
at once, but at the expense of profuse hemorrhage and a 
subsequent traumatic stricture, for the urethra is ruptured 
by the blow. It is hardly necessary for me to add that I 
do not advise your practising any such method. 

When the epididymis is affected, the first step in the 
treatment is to insist upon the patient's going to bed, and the 
old maxim of Malgaigne in such cases is a good one : " The 
patient on his back, and his testicles toward the ceiling." 
Should he at first be restive under such advice, you may 



TREATMENT OF GONORRHEA AND ITS COMPLICATIONS. I9I 

be very sure that sooner or later he will accede to it, for his 
testicles will continually remind him that he is a fool to 
stand when he can lie, and he will perforce be glad to seek 
his bed in order to escape the intense suffering which 
gonorrheal epididymitis involves. 

Of the many local applications which have been employed 
in acute epididymitis, cold ones are the best. Pack the testicle 
in ice, which should be finely broken up and placed in a water- 
tight rubber bag, or, what will answer the same purpose, 
a well-made condom. This will often relieve the pain 
and make the patient comparatively comfortable and easy. 
Poultices of hot flaxseed-meal or of tobacco leaves soaked in 
hot water are sometimes used ; but all these applications are 
nasty messes, and if you deem heat requisite in the treat- 
ment of these diseases, a very good way of applying it is by 
soaking a preparation known in the shops as spongiopiline 
in hot water, and wrapping the testicle up in that. Flannels 
wrung out in hot ivater will oftentimes serve the same pur- 
pose ; but nine times in ten cold applications answer better 
than hot ones. The use of ice should be steadily persevered in 
until the pain is relieved, unless, indeed, its application causes 
discomfort to the patient from too great a degree of cold 
when its use may be intermitted. The testicle, in the mean- 
time, should be well supported and not allowed to hang 
between the patient's thighs. A very neat manner of 
relieving the pain is by making multiple punctures with a 
surgeon's needle, the larger the better, or with a bistoury 
which is guarded to within a quarter of an inch of its point. 
The testis is grasped in the left hand, and several rapid 
punctures are made into the swollen epididymis, care being 
taken not to make them too deep. Blood and serum fol- 
low the punctures, and oftentimes immediate relief is ex- 
perienced. 



192 VENEREAL DISEASES. 

After a week or ten days the pain in the testis subsides, 
and the patient is able to leave his bed, when upon exami- 
nation the epididymis is found enormously enlarged and 
indurated, and still tender upon pressure. This swelling 
gradually subsides, and under very favorable circumstances 
may entirely disappear, but, as I already stated in the last 
chapter, some thickening is nearly always left behind. To 
reduce this, equal parts of unguentum hydrargyri and un- 
guentum belladonnce may be applied to the testicles upon a 
piece of linen or soft kid. Another plan, but one little used 
at the present day, is strapping the testicle in the manner 
described in manuals on surgery ; but as this has sometimes 
led to atrophy of the testis, its general use has been pretty 
nearly abandoned. To relieve the enlargement of the epi- 
didymis iodid of potassium in five- or ten -grain doses, three 
times daily, is sometimes advised, but my experience has 
been that this salt makes the clap zvorse. I, therefore, have 
given up its use, and substitute for it the simple tincture of 
iodin, in five- or ten-minim doses, which I do not find open 
to the same objection as the iodid. 

The treatment of prostatitis has a twofold object, the 
first being the relief of the inflammation of the prostatic 
urethra, and the second the prevention of suppuration in 
the swollen organ. If, upon rectal examination, the pros- 
tate be found very much enlarged and tender, hot fomenta- 
tions should be applied. For the relief of the dysuria, rectal 
suppositories of opium and belladonna should be used, of 
sufficient strength to insure freedom from pain. They 
should be prepared as follows : 

H . Extr. opii, gr. ij 

Extr. belladon., gr. j 

Theobrorrice, q. s. 

Ut fiat suppos. rect. No. 1. 
Sig.— P. r. n. 



TREATMENT OF GONORRHEA AND ITS COMPLICATIONS. 1 93 

Pieces of ice may also be passed up the rectum, and kept 
in apposition to the inflamed prostate. 

Injections in prostatitis should be suspended, nor should 
they be resumed until the acute inflammation has entirely 
passed away. 

The internal remedies which have been advised for this 
complication of gonorrhea are numerous, but to my mind 
four-fifths of them are useless and had better be dropped out 
of the list. The best are copaiba and the oil of yellozv sandal- 
wood, and, if a diluent is required, sweet spirits of nitre, well 
diluted with water, given several times during the day in 
teaspoonful doses. 

When suppuration threatens, the formation of pus should 
be favored as much as possible by the use of hot sitz-baths 
and hot fomentations to the perineum, and the surgeon's 
efforts should be directed to make the abscess point into the 
rectum. As soon as fluctuation is felt, open the abscess and 
dress the part afterward with injections of warm water, to 
which may be added a little carbolic or nitric acid, but these 
should be very weak, the principal object being to keep the 
abscess clean and free from the accumulation of pus or fecal 
matter. The cut edges of the wound will often form a sort 
of valve, which acts as a protection against the retention of 
foreign bodies in the abscess. 

During acute inflammation of the prostate the gonor- 
rheal discharge almost, if not entirely, disappears, to return 
again as soon as the inflammation has passed off, and when 
this occurs, injections can again be used. The patient should 
now be instructed, after throwing in the injection, to work 
it back as far as possible into the canal, and this may be done 
by stroking the urethra from before backward, in order to 
press the fluid into the deeper parts of the canal. The sur- 
geon may himself once or twice a week make a deep injec- 



194 VENEREAL DISEASES. 

tion, with Ultzmann's urethral syringe, of one of the fol- 
lowing preparations : 

R. Argent, nitrat., gr. ss-j 

A q use > Eh 

M. 

SlG. — For deep injections. 

R. Cupri sulph., g 1 *- x-xx 

Aquae, 3 vj— viij. 

M. 

SlG. — For local use. 

These injections should never be intrusted to the patient, 
but the surgeon should always give them himself. Similar 
applications can be made through the endoscope. 

Inflammation of Littres glands a?id of the lacuna magna is 
usually treated through the endoscope. If the latter is the 
seat of trouble, pass a probe-pointed knife into the diseased 
duct and open the canal for its entire length, which can 
easily be done, as it is situated 1 y 2 inches from the meatus, 
when the part may be touched with silver nitrate. A wire- 
frame speculum is usually the best instrument to use for 
reaching this duct. 

Peri-urethral Abscesses. — Every effort should be made in 
cases where suppuration has occurred to prevent the pus 
from discharging externally, by opening the abscess through 
the endoscope, or, when the abscess is near the meatus, by 
the use of the wire-frame speculum, incising the urethra, and 
by external pressure over the swelling to evacuate the pus 
internally. Another way of treating these small abscesses, 
particularly before much suppuration has occurred, is to in- 
ject into them a pj per cent, solution of carbolic acid. When, 
however, siippuration is pronounced, and if the abscess is 
large and difficult to reach with the endoscope, enucleate it, 
pack the cavity with iodoform gauze, and induce healing from 
the bottom. 



TREATMENT OF GONORRHEA AND ITS COMPLICATIONS. 1 95 

Cowperitis. — You must remember that a chronic gojior- 
rlical inflammation of one of Cowper's glands occasionally 
accounts for a persistent discharge from the meatus, and the 
only way to cure this condition is to cure the diseased 
gland. When such is the case, we must depend for our 
.diagnosis upon the history of acute pain and the evidence 
of a swelling to one side of the perineum. This usually sub- 
sides, only to return if the urethra be irritated by instru- 
ments, by external violence, as a blow on the perineum, or 
by excessive sexual indulgence. Although not a common 
condition, it does occur, and in one case which I have seen 
the diagnosis was made during one of the exacerbations. 
Removal of the gland cured the patient of all further trouble. 
Inflammations of this kind are obstinate to all the usual 
forms of treatment and very difficult of diagnosis during an 
intermission. 

Seminal vesiculitis, usually due to the extension of gonor- 
rhea from the urethra into and through the ejaculatory 
ducts to the seminal vesicles, is of two varieties : acute 
and chronic. In the acute stage rest in bed should be en- 
joined, combined with the use of belladonna and opium sup- 
positories, and all local treatment, such as injections, topical 
applications, the passing of sounds, etc., must be discontinued. 
The discharge usually subsides during the acute stage, to 
return, however, as the attack passes off. See that the tes- 
ticles are supported and the bowels moved freely each day by 
enemata of hot water, and to prevent injuring the inflamed 
organs, a soft-rubber catheter should be used instead 
of the ordinary nozzle. The diet should be light, and all 
alcohol strictly forbidden. The treatment is either internal 
(as for acute gonorrhea) or external, and of all the local 
remedies cold applications are the best, either in the shape 
of an ice-bag or as fomentations. If heat is indicated, hot 



I96 VENEREAL DISEASES. 

flaxseed poultices to the perineum will often give relief. 
The acute attack generally lasts from ten days to two weeks. 
In many cases, however, a chronic vesiculitis follows the 
acute attack, frequently attended with a persistent discharge 
from the urethra which no local treatment through this canal 
will help, as the seminal vesicles can not be reached through 
the urethra. The treatment for this inflammation of the 
seminal vesicles must be applied through the rectum. 

Having made our diagnosis, we should strip or massage 
the diseased sacs every five days. At first this may be 
painful and the discharge temporarily increased, but as im- 
provement takes place there is less and less discomfort and 
the discharge finally disappears . The technic of this method 
of treatment is as follows : The patient should present him- 
self with a full bladder and an empty rectum in order to 
facilitate reaching the seminal sacs. He then assumes a 
standing position, with the upper part of the body at right 
angles to the lower. The surgeon, standing behind the 
patient, passes his right or left index-finger into the rec- 
tum, according to which vesicle is to be stripped, the finger 
being kept on a line with the forearm and wrist, when, with 
considerable pressure of the hand against the perineum, 
the vesicles can be reached. Counterpressure is made over 
the pubes with the disengaged hand. The act of stripping 
the sac is accomplished by moving the terminal phalanx 
(not the whole finger) slowly over the vesicle from its upper 
border to the opening of the ejaculatory duct, care being 
taken that, while the pressure is firm, it shall not be violent 
nor shall it cause a great amount of discomfort to the patient. 
If the physician is not strong or the patient is very stout, a 
chair may be placed behind the latter, the physician plant- 
ing his right or left foot on the chair, his elbow on his 
knee, and his finger in the patient's rectum. This position 



TREATMENT OF GONORRHEA AND ITS COMPLICATIONS. 1 97 

will usually give the strength requisite to reach high up 
into the rectum, as it needs a fairly strong arm and wrist to 
overcome the resistance of the perineal muscles. 

For patients with a tubercular tendency or in whom tuber- 
culosis of these organs is present, all local treatment must be 
discontinued, a change of climate advised, and cod-liver oil 
prescribed internally. These cases are very difficult to 
cure, — indeed, are sometimes incurable, — and the surgeon 
should use every means in his power to build up the 
patient's general health. 

Coitus should be interdicted during the treatment, but 
after the massage has been discontinued it may be allowed 
as an aid to recovery. It should always, however, be per- 
formed in the natural manner, and self-abuse should be 
forbidden. 

In chronic gonorrhea where the entire urethra is involved 
the endoscope is very useful for detecting and reaching gran- 
ulations and other diseased areas. Granulations are not in- 
frequently present in some portion of the urethra, giving 
rise to a discharge, and should be treated every four or five 
days by the silver nitrate (i to 10 per cent, strength) ap- 
plied on cotton tampons through the endoscope. 

The treatment of gonorrheal rheumatism is as unsatisfac- 
tory as it can well be, for there is no form of rheumatism 
more rebellious to the action of remedies or more prone to 
become chronic. The ordinary internal remedies are of no 
avail, and those which promise the most success are the 
local application of blisters above and below the diseased 
joints, painting the affected parts with the compound 
tincture of iodin, and the internal administration of the 
iodid of potassium. But even these sometimes prove of 
no service, and the case goes on to anchylosis, partial 
or complete. In cases where pericarditis ensues local 



I98 VENEREAL DISEASES. 

applications of strong tincture of iodin should be made 
over the pericardial region, and iodid of potassium in five- 
to ten-grain doses administered internally three times daily. 
But sometimes permanent thickening of the cardiac valves 
takes place, just as it does in rheumatic pericarditis from 
other causes. 

In addition to the above measures full doses of salol, 
salicylic acid, or quinin are of assistance. , The joint should 
be tightly bandaged and kept at rest, cold applications 
being made during the acute stage and later in the 
disease. 

Gonorrheal ophthalmia is of importance, according to the 
form which it takes, and the treatment varies widely. 
When due to contagion from the conveyal of matter by the 
fingers, the attack is extremely serious, as the eyeball may 
be destroyed within forty-eight hours unless prompt measures 
be taken for its relief. The eyelids and the eye itself should 
be sedulously and carefully kept clean by frequent syring- 
ing with warm water every ten or fifteen minutes ; the eye- 
lids should then be everted, so far as the enormous edema 
and swelling will permit, and the parts brushed over with a 
strong solution of nitrate of silver, forty to sixty grains to 
the fluid ounce of water. The unaffected eye should be 
carefully protected from infection by the use of a watch- 
glass tightly applied by the aid of flexible collodion and a 
bandage. In spite of all care and attention corneal ulcera- 
tion will sometimes go on very rapidly, and the contents 
of the eyeball be evacuated. The subsequent thickening 
and granular condition of the lids, as well as the keratitis 
and chemosis, should be treated by the methods laid down 
in the text-books on ophthalmic surgery. 

The other form of gonorrheal ophthalmia is not so serious. 
The conjunctivitis and the serous iritis may be treated by 



TREATMENT OF GONORRHEA AND ITS COMPLICATIONS. 1 99 

repeated bathing with hot water, blisters to the temples, and 
the instillation of the following collyrium : 

]£ . Sodse bicarbonat., gr. x 

Aquae camph., 25 ij. 

M. 

Sic— P. r. n. 

Serous iritis may be treated by dropping into the eye, 
three or four times daily, the sulphate of atropin, four grains 
to the ounce of water. If the iris remains sluggish to the 
action of the atropin, one or two leeches may be applied 
to the temple or over the supra-orbital region. 

Inflammation of the lymphatic inguinal glands, or those 
running over the dorsum penis, should be treated in the 
earlier stage by rest, cold applications, pressure, blisters, 
and the daily application of the tincture of iodin. Should, 
however, these measures prove ineffective to prevent sup- 
puration, it should be favored, as far as possible, by the 
application of poultices, and as soon as fluctuation is de- 
tected the bubo should be opened in the method laid down in 
the chapter on chancroidal buboes, care being taken that 
all sinuses are freely laid open and curetted whenever they 
present themselves. The wound should then be irrigated 
with hydrogen peroxid and packed with iodoform gauze. 

After the discharge has lost its purulent character and 
subsided into the chronic condition known as gleet, the treat- 
ment undergoes certain modifications. If dependent upon 
a stricture, this must be removed before the discharge can 
be cured, which may be done either by gradual dilatation 
with bougies and sounds or else by one of the many opera- 
tions advised in the surgical text-books. Once or twice 
a week the surgeon should pass a steel sound of the 
largest size the urethra is capable of receiving, which may 
be withdraivn within a few seconds after its introduction 



200 VENEREAL DISEASES. 

into the bladder, or left in situ for five to fifteen minutes, as 
occasion requires. A steady perseverance in this course of 
treatment for a few weeks will generally bring about a cure, 
which may be hastened in some instances by the use of deep 
injections and by the internal administration of the balsamic 
and resinous preparations of which I have already spoken. 
This brings me to one point of my subject which it is 
well for you to remember : a discharge is sometimes kept up 
by overmedication. Patients will apply to you with the fol- 
lowing history : they have been under treatment two or 
three months for a gonorrhea, which, after running through 
its usual course, has ended in a thin, mucous discharge, 
usually only apparent in the morning, but occasionally 
during the day. There is no irritation while passing water, 
and but for the slight discharge they would be entirely well. 
This, however, has persisted for several weeks without any 
apparent change, and has been a source of worry and 
anxiety. The patients have lost flesh and strength, w r hile 
their faces will often bear signs of the mental excitement 
under which they are laboring. Bid such patients throw 
away their syringes, stop all injections and medicines ; bid 
them live well, and use with their dinners a moderate quan- 
tity of some light wine — the red Bordeaux wines are the 
best ; advise them against beer and spirits at first, but these 
may be used later on if deemed requisite. Tell them plainly 
that they are keeping up the discharge by ovcrtrcatment, and 
that the sooner they recognize the fact, the quicker they 
will get well. Sometimes nothing further will be needed, 
but occasionally some tonic, such as the tincture of the 
chlorid of iron or the syrup of iodid of iron, in doses of five 
to fifteen minims, may be given with advantage, and you 
will have the gratification of hearing the patients tell you in 
a short time that they are entirely well. 



TREATMENT OF GONORRHEA AND ITS COMPLICATIONS. 201 

Warts, or condylomata, as they are sometimes called, if 
small and pedunculated, may be snipped off with scissors 
and their bases touched with strong nitric or acetic acid. 
When they are large, or seated upon a broad base, they 
should be painted with strong acetic acid, and dusted over 
with powdered alum or with the dried sidphate of iron, 
mixed with equal parts of lycopodium. When very large 
and exuberant, especially in those cases which occur in both 
sexes on the nates and perineum, I have often injected two 
or three minims of glacial acetic acid into the substance of 
the wart with benefit. This shrivels up the growth with 
surprising rapidity, and, when properly used, by injecting 
but a few drops at a time, is not attended with any danger ; 
at the most, an abscess is the worst result that will follow, 
unless, of course, the acid is used recklessly and beyond 
the bounds of prudence. But one point I wish particularly 
to impress upon your minds in the treatment of these 
affections : keep the parts dry and clean ; it is four-fifths of 
the treatment. 

Herpes, when slight, is best treated by dusting the parts 
with powdered bismuth or starch and zinc, calamin, or some 
such dressing ; if they show any tendency to ulcerate, touch 
them lightly with the solid nitrate of silver, and finish the 
treatment with the dry dressing above advised. Do not use 
wet dressings ; they only serve to macerate the epithelium 
and keep the parts in a condition of moisture unfavorable 
to recovery. 

When complicated with digestive troubles, these latter 
must be treated by the remedies applicable to such diseases. 

The treatment of gonorrhea in women varies according to 

the portion of the genitals which is attacked. In urethritis 

and folliculitis, the varieties most frequently encountered, 

the internal treatment and diet are much the same as in 

i7 



202 VENEREAL DISEASES. 

men ; potassium acetate or bicarbonate of soda is given in 
the acute stage, to be followed later on by urethral injec- 
tions or by the application of the solid stick of silver nitrate. 
As the acute stage subsides the local lesions in the urethra 
are treated through the endoscope, by topical applications 
made directly to the diseased part in the form of aqueous 
solutions of silver nitrate, I to 10 per cent., or a 2 to 10 per 
cent, solution of iodin in glycerin. Urethritis in the female 
is much less serious than in the male, and recovery is gen- 
erally much more rapid and complete. 

In the treatment of vulvitis cleanliness is very important, 
careful attention to which will assist very much in the cure 
of the disease. The use of antiseptic and astringent lotions, 
combined with an effort to protect the inflamed surfaces 
from the irritating effect of the urine and of the discharge, 
is essential. 

Hot solutions of corrosive sublimate, I : 2000, silver nitrate, 
1 : 1000, are the best, the injections being made with a 
fountain syringe and a large quantity of fluid being used. 
In addition the inflamed surfaces should be separated by a 
thin sheet of cotton dipped in some mild antiseptic, for 
which, after the acute symptoms subside, astringent powders 
and dry cotton may be substituted. 

The treatment of Bartholinitis is rest in bed, hot sitz- 
baths, and soothing lotions constantly repeated. As soon as 
pus is detected, an incision should be made on the inner 
surface of the labium majus, the pus evacuated, and the cav- 
ity curetted and packed with iodoform gauze. This should 
be kept open, thoroughly washed out with peroxid of 
hydrogen or bichlorid, 1 : 2000, and allowed to heal from 
the bottom. Chronic Bartholinitis is extremely difficidt to 
cure, showing a tendency to recur, resisting all ordinary 
treatment, and often necessitating removal of the gland. 



TREATMENT OF GONORRHEA AND ITS COMPLICATIONS. 203 

In the treatment of gonorrheal vaginitis, the vagina being 
first cleansed by the use of tampons of prepared cotton in- 
troduced through the speculum, should then be painted 
over with a strong solution of nitrate of silver (twenty to 
forty grains to one ounce of water) or the pure tincture of 
iodin. If care is taken not to allow the fluid 'to run out upo?z 
the vulva or the external genitals, no pain is felt, as the 
vagina and the cervix uteri are not sensitive parts ; and 
even if the medication does reach those portions, the smart- 
ing is not very severe nor does it last long. Upon the 
withdrawal of the speculum a layer of dry cotton is placed 
between the labia, to separate them as well as to prevent 
the discharge from trickling down over the perineum and 
the insides of the thighs, and to obviate excoriation of these 
parts. 

The patient herself may use hot antiseptic injections, a 
quart at a time, twice daily, and the best is one of corrosive 
sublimate, I : 2000. After injecting, the vagina should be 
tamponed with sterilized gauze. 

A very good injection is to add to a half-pint of ordinary 
table claret : 

R. Alum, pulv., . ^ij 

Zinci sulph., !|j 

M. 

Of which the patient is directed to use from one to three 
tablespoonfuls in from one-half to a full pint of tepid water 
thrice daily. 

It is well, for convenience, to give women the materials in 
bulk, and let them mix their injections themselves, reckon- 
ing a full, not a heaping, teaspoonful as the equivalent of 
the drachm. 

If the inflammation is very acute, no injection should be 
used except one of hot water, and the frequent use of hot 



204 VENEREAL DISEASES. 

sitz-baths is advisable, but as soon as the symptoms subside 
the medicated fluids should be employed. 

A very good way of keeping the medication in contact with 
the diseased part is to soak a pledget of prepared cotton in 
a solution of tannic acid two drachms to glycerin one ounce, 
and lay it on the diseased portions of the vagina. Other 
astringents may be used in the same manner, such as alum 
of the same strength as the tannin given above, or the 
tincture of catechu without the glycerin. Be careful to 
remove these tampons frequently (three or four times daily), 
else trouble will ensue from decomposition of the retained 
discharge, and also remember that in all these diseases 
cleanliness, if not superior to, is next to, godliness. 

In using injections, in order to make them effective the 
following rules should be observed. The glass and rubber 
syringes which are often sold under the name of vaginal 
syringes are of no earthly use ; the only effective one is the 
fountain syringe. In giving an injection the woman should 
never be allowed to assume a squatting posture, as the fluid 
runs out as fast as it is thrown in, and does not reach the 
deeper portions of the canal ; but she should be placed upon 
her back, with the hips slightly elevated, when the vagina is 
thrown open by the force of gravity, and the fluid, by the 
same physical action, is carried into every portion of the 
canal. Some of the fluid, of course, escapes ; and in order 
to protect the woman's clothing, a sheet of rubber cloth 
should be placed under the hips, and a vessel in readiness 
to catch the overflow. At the close of the operation a 
tampon of dry cotton should be placed between the labia, to 
retain what fluid is left in the canal. These injections, re- 
member, are to be used in conjunction with the applications 
which the surgeon makes himself eveiy second or third 
day. 



TREATMENT OF GONORRHEA AND ITS COMPLICATIONS. 205 

In inflammation of the cervix uteri the part should first 
be thoroughly cleansed from all discharge with a piece of 
cotton wound on the end of a uterine probe, and the canal 
touched with a solid stick of the nitrate of silver, care being 
exercised that the cervix alone, and not the body of the 
uterus, is cauterized. The patient should not be trusted to 
make any applications herself, owing to the danger of ex- 
citing inflammation in the body of the womb, the treatment 
of this portion of the woman's genitals being left entirely in 
the surgeon's hands. 

During the acute stage of endometritis no local treatment 
should be applied. Rest in bed, free use of saline laxatives, 
local depletion of the cervix, and anodynes are indicated ; but 
later on, when the disease has become chronic, the uterus 
should be washed out every two or three days with a hot 
bichlorid solution, I : 10,000, and, if necessary, the cervix 
should be dilated and the cavity of the uterus curetted. 
When the Fallopian tubes and ovaries are involved, rest, 
leeches, and anodynes should be employed, and as soon as 
a tumor can be distinctly felt, an abdominal or a vaginal 
section should be made. Internal treatment, so far as the 
local conditions are concerned, is not of much advantage , 
except in urethritis. 



INDEX 



Abortions caused by syphilis, 137 
Abortive treatment of gonorrhea in 

the male, 175 
Abscess, causes of peri-urethral, in 
gonorrhea, 157 
peri-urethral, in gonorrhea, 156 
situation of, 156 
symptoms in, 157 
treatment of, in gonorrhea, 

194 
Acids in local treatment of chancroid, 

3 1 

Acquired syphilis. See Syphilis. 

Adenitis from gonorrhea, 168 

gummosa, characteristics of, 80 
universalis, description of, 79 
Age. influence of, in syphilitic nervous 

lesions, 98 
Air-passages, syphilitic affections of 

the, 87 
Alcohol forbidden to gonorrheal pa- 
tients, 178, 186, 195 
to venereal patients, 40 
Alimentary canal, syphilitic affections 

of, 93 
Alopecia syphilitica, early, 72, 129 

late, 72, 129 
Anus, chancroids of the, 29 
Ardor urinae, mitigation of, 185 
Arteritis syphilitica, 94 
Atrophy in syphilis hereditaria tarda, 
134 



B. 

Bacillus as cause of syphilis, 52 
of the chancroid, 19 



Bacterium, the, of hereditary syphilis, 

J 35. . 
Balanitis in gonorrhea, 154 
Balanoposthitis, causes of, 1 54 
gonorrheal, 154 

treatment of, in gonorrhea, 
188 
Bartholin, affections of the glands of, 

in gonorrhea, 150 
Bartholinitis, treatment of gonorrheal, 

202 
Baths, vapor, in treatment of acquired 

syphilis, 116 
Blood as source of contagion in syph- 
ilis, 50 
Bones, affections of the, in acquired 
syphilis, 101 
in hereditary syphilis, 13 1 
gummatous affections of the, in 

acquired syphilis, 102 
necrosis of the, in acquired syph- 
ilis, 102 
in hereditary syphilis, 133 
Bougies, medicated, in treatment of 

acute gonorrhea, 182 
Brain, affections of the, in acquired 
syphilis, 94 
in hereditary syphilis, 125 
Bubo, application of leeches in chan- 
croidal, 38 
breaking up of the nonvirulent, 

in acquired syphilis, 39 
site of chancroidal, 27 
sympathetic, in chancroid, 26 
virulent, in chancroid, 26 
Buboes in women, 30 

incision in the treatment of chan- 
croidal, 39 
treatment of chancroidal, 37 
Bullae. See Syphilides. 



207 



208 



INDEX. 



C. 

Cachexia, definition of syphilitic, 

103, 121 
Cartilage, affections of the, in acquired 

syphilis, 103 
Carunculae lachrymales, svphilides of 

the, 85 
Cautery in local treatment of chan- 
croid, 31, 39 
Cervicitis in gonorrhea, 174 

treatment of gonorrheal, 205 
Chancre, "mixed," 52 

reason for abandoning the name, 

42 
See Lesion. 
Chancroid, absence of induration in, 
24 
appearance of edges in, 23 
auto-inoculability of, 23, 25 
bacillus of, 19 
bubo in, 25 

destructive character of, 22, 27 
differential diagnosis between 
ulcerating gummata and the, 
69, 70 
irregular shape in, 23 
is a local disease, 17 
local dry dressings in, 32 
never produces syphilis, 92 
period of incubation in, 18 
phagedena in, 28 
phimosis occurring in, 29 
resemblance between an ulcer- 
ating gumma and a, 69, 78 
seat of, 27 
secretion in, 23, 25 
serpiginous, 28 
treatment of urethral, 36 

when seated at the frenum, 

37 
uneven floor in, 23 
virus of, 22 

wet dressings in treatment of, ^ 
Chancroids, gangrene as a compli- 
cation of, 35 
heat in treatment of, 34 
internal treatment in, 39 
local treatment of, 31 

by the actual cautery, 

31 

of the anus, 29 

of the female genitals, 30 

treatment of phagedenic, 40 



Chancroid, treatment of, when com- 
plicated with phimosis, 34 
Chordee in gonorrhea, 157 

treatment of, 189 
Choroiditis syphilitica, 84 
Complications which occur in gonor- 
rhea, 154 
Contagion, syphilitic, not induced by 

physiological secretions, 49 
Cord, gonorrheal inflammation of the 

spermatic, 163 
Cowperitis, causes of, 158 
in gonorrhea, 158 
symptoms of acute, 159 
treatment of gonoiTheal, 195 
Cyclitis syphilitica, 84 
Cystitis, gonorrheal, 166 



D. 

Dactylitis syphilitica, 132 
Deafness from acquired syphilis, 86 
in syphilis hereditaria tarda, 130, 

Definition of venereal diseases, 17 
Description of gonorrheal endometri- 
tis. 174 
Development, lack of, in syphilis 

hereditaria tarda, 134 
Differential diagnosis. See Gonor- 
rhea. 
Diplococcus in urethral and vaginal 
discharges apart from gonorrhea, 
144 
Discharge, every urethral, in the 
male not necessarily gonor- 
rheal, 142, 145, 147 
See Urethral. 

sometimes due to overmedica- 
tion, 200 
Duration of acquired syphilis, 123 
of gonorrhea in men, 150 

in women, 149 
of inherited syphilis, 132 



Ear, affections of the, in acquired 
syphilis, 85 
in hereditary syphilis, 130 
Endometritis in gonorrhea, 174 
treatment of gonorrheal, 205 



INDEX. 



209 



Epididymis, syphilis of die, 90, 131 
Epididymitis, differential diagnosis 
between syphilitic and gonor- 
rheal, 162 
gonorrheal, time of appearance 
of, 161 
treatment of, 190 
in gonorrhea, 161 
Epilepsy in acquired syphilis, 97 
Erythema maculatum, description of, 
61 
papulatum, description of, 62 
syphiliticum, definition of, 59 
Esophagus, syphilis of the, 89 
Etiology of acquired syphilis, 49 

of inherited syphilis, 135 
Eyelids, affections of, in acquired 

syphilis, 8 1 
Eyes in acquired syphilis, 81 et seq. 
in syphilis hereditaria, 130, 134 



Fever, nocturnal syphilitic, 59 
Finger-nails in acquired syphilis, 73 
Fingers, affections of, in acquired syph- 
ilis, 73 
in hereditary syphilis, 131 
Folliculitis, treatment of gonorrheal, 
in women, 201 



Gangrene as complication of chan- 
croids, 35 
Genitals, in syphilis acquisita, 90 

hereditaria tarda, 131, 134 
Gland, thymus, in hereditary syphilis, 

128 
Glands, condition of, in initial lesion, 
48 
in hereditary syphilis, 128 
of Littre, gonorrheal inflamma- 
tion of, 156 
Gleet, definition of, 145 
Gonococcus of Neisser, description 

of, 143 

in gonorrhea, 141 

pathognomonic of gonor- 
rhea, 142, 153 

18 



Gonorrhea a cause of sterility, 145, 

163 
abortive treatment of, in the 

male, 175 
adenitis from, 168 
affections of the cornea in, 171 
of the glands of Bartholin 

in, 150 
of the heart in, 170 
of the rectum in men and 

women, 14 1 
of the tendons in, 142, 169 
antiseptic injections in acute, of 

the male, 145, 179 
as a constitutional disease, 141 
as a local disease, 141, 178 
astringent injections in the treat- 
ment of acute, 183 
balanitis in, 154 
cause of ophthalmia in, 141 
characterized by gonococcus of 

Neisser, 141, 153 
chordee in, 157 
complications of, 154 
cystitis from, 166 
definition of, 141 
description of acute, in the fe- 
male, 150 
in the male, 145 
difference between simple and 

specific, 142 
differential diagnosis between 
the concealed chan- 
croid and, 148 
between the concealed 
initial lesion and, 148 
duration of, of men, 150 

of women, 149 
general infection of the system 

in, 141 
herpes in, 173 
hydrocele in, 162 
in the male contracted by sod- 
omy, 142 
due to urethral stricture, 149 
in women, 150 
incubation period in, 145 
inflammation of the glands of 
Littre in, 156 
of the lacuna magna in, 

156 
of the spermatic cord in, 
163 



2IO 



INDEX. 



Gonorrhea, internal medication in, of 
the male, 185, 193 
invasion of the kidney by, 166 
iridoscleritis in, 170 
lymphangitis from, 168 
methods of contracting, 141 
never produces syphilis, 92 
ophthalmia neonatorum from, 

141 
organs most frequently attacked 

in, 141 
pain in the os calcis due to, 

169 
peri-urethral abscess in, 157 
seminal vesiculitis in, 164 
symptoms in the urine of inva- 
sion of the posterior urethra 
in, of the male, 161 
the gonococcus of Nekser in, 

141, 153 
treatment of, 175 

of acute inflammatory, 178 
of balanoposthitis in, 188 
of, by recurrent irrigations, 

176 
of chronic, due to stricture, 

of cowperitis in, 195 

of disease of Bartholin's 

glands in, 202 
of inflammation of Littre's 
glands in, 194 
of the lacuna magna 
in, 194 
of ophthalmia in, 198 
of paraphimosis in, 188 
of periurethral abscess in, 

194 
of phimosis in, 188 
of prostatitis in, 192 
of rheumatism in, 197 
of seminal vesiculitis in, 195 
of the affections of the cer- 
vix uteri in, 205 
of the epididymis in, 

190 
of the posterior urethra 

in chronic, 187 
of the uterus in, 205 
of vaginitis in, 203 
of vulvitis due to, 202 
use of injections in treatment of 
acute, in the female, 203 



Gonorrhea, use of injections in treat- 
ment of acute, in the 
male, 179 
medicated bougies in treat- 
ment of acute, 182 
warts in, 172 
Gonorrheal adenitis, 168 
balanitis, 154 
cervicitis, 174 
cowperitis, 158 
endometritis, 174 
epididymitis, 161 
lymphangitis, 168 
posthitis, 154 
prostatitis, 159 
rheumatism, 169 
Gout may cause urethritis, 148, 149 
Gummata, description of nonulcer- 
ating, 69 
of ulcerating, 69 
differential diagnosis between 
ulcerating, and chancroids, 70 
resemblance between ulcerating, 
and chancroids, 70 



H. 

HEMORRHAGICA, syphilis, neona- 
torum, 127 
I lair, affections of, in acquired syph- 
ilis, 72 
in hereditary syphilis, 129 
in early syphilis, 72 
in late syphilis, 72 
Heart, affections of the, in gonorrhea, 

170 
Heat in treatment of chancroids, 34 
Hemicrania in acquired syphilis, 96 
Hemiplegia in acquired syphilis, 97 
symptoms of, in syphilitic affec- 
tions, 98 
Herpes in gonorrhea, 173 

treatment of, 201 
Hyalitis syphilitica, 84, 85 
Hvdrocele, gonorrheal, 162 



I. 

Icterus syphiliticus. 93 
Idiocy in acquired syphilis. 97 
Immunity of the mother from con- 
tracting syphilis from the child, 50 



INDEX. 



21 I 



Incubation in gonorrhea, 145 

length of, in early stages of syph- 
ilis. 43 
of initial lesion, 43 
period of, between the appear- 
ance of the earlier 
stages in syphilis, 58 
the different syphilides, 
72 
Infection of the system in gonorrhea, 
141 
source of, in syphilis, 49 
Injections, antiseptic, in acute gon- 
orrhea of the 
female, 203 
of the male, 179 
astringent, in treatment of acute 
gonorrhea 
in the fe- 
male, 202 
in the male, 

183 
subcutaneous, in treatment of 

acquired syphilis, 1 18 
the proper way to administer 
urethral, in the male, 181 
Inunctions in treatment of acquired 

syphilis, 1 15 
Iodin as an alternative for iodid of 
potassium in acquired syphilis, 121 
Iodoform, objections to use of, 32, 54 
Iridoscleritis, gonorrheal, 170 
Iritis, gummatous, 83, 84 

syphilitica, 82, 130 
Irrigations in the treatment of gonor- 
rhea, 176, 180 
Itching, absence of, in syphilides, 
61 

J- 

Joints, affections of the, in syphilis 
hereditaria tarda, 132, 134 

K. 

Keratitis, gonorrheal, 171 
syphilitica, 81, 130, 134 
Kidney attacked by gonorrhea, 166 



Lachrymal gland, syphilides of, 85 
Lacuna magna, gonorrheal inflamma- 
tions of, 156 



Lacuna magna, treatment of inflam- 
mation of, in gonorrhea, 194 
Leeches, application of, in treatment 

of chancroidal bubo, 38 
Lesion, abortive treatment of the ini- 
tial, 55 
bubo accompanying initial, 46 
cautery in treatment of initial, 

54, 106 
characteristics of initial, 44 
condition of glands in initial, 48 
dry dressings in the treatment of 

the initial, 54 
exceptions to nonauto-inoculabil- 

ity of initial, 45 
induration of initial, 44, 45, 46 
initial, always the first symptom 
of acquired syphilis, 42 
is synonym of chancre, 42 
not auto-inoculable as a rule, 

45 
not destructive, 42 
internal treatment in the initial, 

5 6 
nontendency of initial, to spread, 

44 

period of incubation of initial, 43 
secretion in initial, 44, 45 

of initial, as source of syph- 
ilis, 49 
singleness of initial, 44 
site of initial, 49 
the floor of ulcer in initial, 48 
treatment of the initial, 54 
wet dressings in the treatment of 
initial, 55 
Littre's glands, treatment of inflam- 
mation of, in gonorrhea, 194 
Local preparations in treatment of ac- 
quired syphilis, 1 12 
Lupus syphiliticus, 133 
Lymphangitis from gonorrhea, 168 
Lymphatics in hereditary syphilis, 128 



M. 

Mamm.e, the, in syphilis hereditaria 
tarda, 134 

Mania in acquired syphilis, 97 

Massage in gonorrheal seminal vesicu- 
litis, 196 

Medication, internal, in the treatment 
of gonorrhea in the male, 185 



212 



INDEX. 



Medication, over-. See Discharge. 
Melancholia in acquired syphilis, 97 
Menstruation in syphilis hereditaria 

tarda, 134 
Mental powers, the, in syphilis hered- 
itaria tarda, 134 
Mercury, directions for use of, in ac- 
quired syphilis, 56, 106, 107, 
119, 120 
in the treatment of hereditary 

syphilis, 137, 138 
varieties of, in the treatment of 
acquired syphilis, 108 
Mixed sore, the, really a double in- 
fection, 53 
treatment in acquired syphilis, 

113 

in hereditary syphilis, 138 
Mortality in hereditary syphilis, 135 
Mucous membranes, symptoms of the, 
in acquired syphilis, 

74 
in hereditary syphilis, 
127 
Muscles, paralysis of muscles or sets 
of, in acquired syphilis, 99 



N. 

Nails, affections of the, in heredi- 
tary syphilis, 128 
in early acquired syphilis, 73 
in late acquired syphilis, 73 
Necrosis. See Bones. 
Nerves, affections of, in syphilis 
hereditaria tarda, 133 
of special, in acquired syph- 
ilis, 99 
of the spinal, in acquired 
syphilis, 101 
Neuritis syphilitica, 85 
Nose, affections of the, in acquired 
syphilis, 87 
in syphilis hereditaria tarda, 
133 



Onychia syphilitica. See Nails. 
Ophthalmia caused by gonorrhea, 170 
gonorrheal, symptoms of, 170 
the two varieties of, 170 



Ophthalmia, gonorrheal, treatment 
of, 198 
neonatorum in gonorrhea, 141 
Orchitis syphilitica, 90 
Os calcis, pain in, in gonorrhea, 169 
Ovaritis syphilitica, 91 
Ozena syphilitica, 87, 133 



P. 



Pain, absence of, in syphilitic testis, 

90 
Pains, osteocopic, in acquired syph- 
ilis, 101 
Palate, affections of the, in acquired 
syphilis, 87 
in hereditary syphilis, 13 } 
Papulae lenticulares, description of, 

65 
miliares, description of, 63 
squamosa?, description of, 65 
Paralysis of special muscles in ac- 
quired syphilis, 99 
Paraphimosis in gonorrhea, 156 

treatment of. 188 

Paraplegia in acquired syphilis, 97 

in hereditary syphilis, 133 

symptoms of syphilitic, 98 

Patches, mucous, description of, 75 

of the lips and cheeks, 75 

of the mouth, 76 

of the throat, 76 

of the tongue, 76 

of the tonsils, 76 

secretion of, as source of 

syphilis, 49, 138 
ulceration of, 77 
Penis, gummous affections of, in syph- 
ilis, 92 
Perivesiculitis, 165 
Phagedena as complication of syph- 
ilis, 51, 106 
causes of syphilitic, 51 
chancroidal, 28 

treatment of, in chancroids, 40 
Pharynx, syphilis acquisita of the, 87 

hereditaria of the, 127 
Phimosis as a complication of syph- 
ilis, 29, 51 
causes of, besides gonorrhea, 155 
gonorrheal, 155 
occurring with chancroids, 29 



INDEX. 



213 



Phimosis, operation for relief of chan- 
croidal, 36 
treatment of, in gonorrhea, 188 
Phlegmona, subcutaneous, in heredi- 
tary syphilis, 127 
Polymorphism in early syphilides, 63 
Posthitis in gonorrhea, 154 
Potassium, iodid of, in the treatment 
of acquired syphilis, 

:I 3> IJ 9 

of hereditary syphilis, 

137, 138 
rules for the use of iodid of, in 
treatment of acquired syphilis, 
114, 119, 120 
Prodromata of the early syphilides, 

59 
Prostatitis, gonorrheal, symptoms of, 
160 
treatment of, 192 
in gonorrhea, 1 59 
Pustulae. See Syphilides. 

crustaceoe, description of, 68 



Rectum, affections of the, in gonor- 
rhea, 141 
disease of the, in acquired syph- 
ilis, 93 
Retinitis syphilitica, 85 
Rheumatism due to gonorrhea, 169 
treatment of gonorrheal, 197 



S. 

SCLERITIS syphilitica, 82 
Serpiginous chancroid, 28 
Skin, affections of the, in syphilis 
hereditaria tarda, 125 
lesions of the, in acquired syph- 
ilis, 60 
Sodomy, rectal gonorrhea in the male 

the result of, 142 
Sore, hard, inadvisability of term, 46 
soft, inadvisability of term, 24, 
46 
Speech, the, in syphilis acquisita, 88 

hereditaria tarda, 134 
Sterility caused by gonorrhea, 163 
Stricture, description of symptoms in- 
duced by urethra], in the male, 167 



Stricture, discharge in the male caused 
by urethral, 149, 167 
of the urethra in the male as re- 
sult of gonorrhea, 167 
in women, 151 
treatment of urethral, dependent 
on chronic gonorrhea, 199 
Syphilides, absence of itching in, 61 
bullous, in acquired syphilis, 70 
in hereditary syphilis, 124 
circinate form of papular, 64 
course and appearance of the 

varieties of, 71 
description of, of the mucous 
membrane, 74 
of pustular, 67 
of tuberculocrustaceous, 69 
duration of the various, 72 
early, of the fauces, 74 
of the tongue, 74 
incubative stage of early, 58 
nomenclature of, 57 
of the buccal cavity, 74 
of the carunculae lachrymales, 85 
of the choroid, 84 
of the ciliary body, 84 
of the conjunctivae, 81 
of the cornea, 8 1 
of the eyelids, 81 
of the iris, 82 
of the lachrymal gland, 85 
of the mucous membranes, 74 
of the sclera, 82 
of the skin, 57 
period of incubation between the 

different, 72 
polymorphism in early, 63 
squamous, of the hands and feet, 

66 
treatment of, 107 
tubercular, 69 

ulcerative, of the mucous mem- 
branes, 77 
vesicular, in acquired syphilis, 

70 
in hereditary syphilis, 127 

Syphilis, acquired, always begins with 

initial lesion, 42, 43 

of the air-passages, 87 

of the ear, 85 

of the epididymis, 90 

of the esophagus, 89 

of the hyaline membrane, 84 



2I 4 



INDEX. 



Syphilis, acquired, of the nose, $J 
of the palate, 87 
of the pharynx, 87 
of the retina, 85 
of the testicles, 90 
of the tongue, 89 
of the trachea, 88, 104 
of the vocal cords, 88 
usually occurs but once in 

a lifetime, 43 
affections of the alimentary canal 

in acquired, 93 
of the arteries in acquired, 

94 

of the bones in acquired, 

101 

in hereditary, 131 

of the brain in acquired, 94 

of the cartilage 111 acquired, 

103, 104 
of the ears in hereditary 130 
of the eyes in acquired, 81 

in hereditary, 130 
of the hair in hereditary, 129 
of the internal viscera in 

hereditary, 131 
of the joints in, hereditaria 

tarda, 132, 134 
of the nails in hereditary, 

128 
of the nose in, hereditaria 

tarda, 133 
of the ovaries in acquired, 

91 
of the palate in, hereditaria 

tarda, 133 
of the skin in, hereditaria, 

125 
of the spinal nerves in ac- 
quired, 10 1 
of the teeth in hereditary, 

129 
of the tendons in acquired, 

104 
of the testicles in acquired, 
90 
in hereditary, 131 
of the trachea in acquired, 

88, 104 
of the uterus in acquired, 91 , 

92 
as a cause of abortions, 137 
atrophy in, hereditaria tarda, 134 



Syphilis, bubo in acquired, 46 

cachexia in acquired, 70, 103, 

121 
cleanliness important in treat- 
ment of acquired, 1 12 
complicated with phagedena, 51 

with phimosis, 5 1 
deafness from acquired, 86 

in, hereditaria tarda, 13 1 
disease of the nervous system in 
acquired, 99 
of the rectum in acquired, 

93' 
of the viscera in acquired, 

93 
divisions of hereditary, 124 
early symptoms in hereditary, 

125 

epileptiform seizures in acquired, 

97 

glands in inherited, 128 

gummatous affections of the bones 
in acquired, 131 
of the penis in acquired, 
92 

hemorrhagica neonatorum, 127 

hemicrania in acquired, 96 

hemiplegia in acquired, 97 

hereditary, at birth, 124 

idiocy in acquired, 97 

immunity of the mother from 
contracting, from the. child, 
136, 138 

inunction in treatment of ac- 
quired, 115 

iodid of potassium in the treat- 
ment of hereditary, 137, 138 

is a constitutional disease, 17, 
42 

jaundice in acquired, 93 
in hereditary, 131 

joints in, hereditaria tarda, 132, 

13+ 

lack of development in, heredi- 
taria tarda, 134 • 

length of incubative stage in 
acquired, 43 

lesions of the skin in hereditary, 
1 24 et seq. 

lymphatics in acquired, 79 
in hereditary, 128 

mania in acquired, 97 

melancholia in acquired, 97 



INDEX. 



215 



Syphilis, menstruation in, hereditaria 
tarda, 134 
mercury in the treatment of ac- 
quired, 55, 56 
of hereditary, 1 1 5, 137 
mixed treatment in acquired, 1 13 
mortality in hereditary, 135 
necrosis of the bones in acquired, 
87, 102 
in hereditary, 1 32, 133 
nervous symptoms in acquired, 96 
in, hereditaria tarda, 132 
never derived from gonorrhea, 92 
never results from chancroid, 92 
nocturnal character of headache 
in acquired. 96 
fever in acquired. 59 
not induced by physiological se- 
cretions, 49 
objection to term secondary, 57 

tertiary, 57 
osteocopic pains in acquired, 10 1 
paralysis of special muscles in 

acquired, 99 
paraplegia in acquired, 97 

in hereditary, 133 
part played by age in nervous 

lesions of acquired, 98 
preparations in local treatment 

of acquired, 54 
proper nomenclature for different 

stages of, 124 
rules for the administration of 
mercury in ac- 
quired, 56 
in hereditary, 137 
subcutaneous injections in treat- 
ment of acquired, 1 18 
p'hlegmona in hereditary, 
127 
symptoms of mucous membranes 
in acquired, 74 
in hereditary, 127 
the bacillus of acquired, 52 
the bacterium of hereditary, 135 
the etiology of acquired, 49 

of hereditary, 135 
the genitals in, hereditaria tarda, 

131 

the mental powers in, hereditaria 

tarda, 134 
the speech in, hereditaria tarda, 

134 



Syphilis, the teeth in, hereditaria 
tarda, 129 
the two periods of incubation in 

early acquired, 58 
the voice in, hereditaria tarda, 

135 
topical treatment in acquired, 1 12 
treatment of acquired, 106 

of hereditary, 137 
ulcerations in, hereditaria tarda, 

133, 134, 135 

use of iodid of potassium in 
treatment of acquired, 113, 119 

usual date of appearance of symp- 
toms in hereditary, 125 

vapor baths in treatment of ac- 
quired, 116 

vesicular syphilides in heredi- 
tary, 126 

virus of acquired, 19, 22, 52 



Teeth, affections of the, in heredi- 
tary syphilis, 129 
Tendons, affections of the, in acquired 
syphilis, 104 
in gonorrhea, 142, 169 
Testicles, affections of the, in ac- 
quired syphilis, 90 
in hereditary syphilis, 131 
Testis, absence of pain in syphilitic, 
90 
i Thymus gland. See Gland. 
i Tongue, affections of the, in acquired 
syphilis, 89 
Trachea, affections of the, in acquired 

syphilis, 88, 104 
Treatment, internal, in chancroids, 39 
local, of the chancroid, 31 
of acquired syphilis, 106 

cleanliness important 
in, 112 
of acute inflammatorv gonorrhea. 

178 
of chancroids when complicated 

with phimosis, 34 
of gonorrhea and its compli- 
cations, 175 
of initial lesion, 54 

abortive treatment in, 

55 
of syphilides, 107, 1 18 



2l6 



INDEX. 



Treatment, topical, in acquired syphi- 
lis, 112 
rules for the use of iodid of po- 
tassium in the, of acquired 
syphilis, 114, 119, 120 
for the use of mercury in 
the, of acquired syphilis, 
56, 119, 120 
various methods of, in hereditary 
syphilis, 137 
Tripperfaden, importance of, 144 
Tubercular syphilides, description 

of, 69 
Tuberculosis of the vesiculse semi- 
nales, 164, 166, 197 



U. 

Ulcerations of syphilis hereditaria 

tarda, 133, 134, 135 
Urethra, treatment of the posterior, 

in chronic gonorrhea, 187 
Urethral discharge in the male not 

necessarily gonorrheal, 142, 147 
Urethritis, gonorrheal, in women, 151 
may be caused by gout, 1 48, 149 
nonspecific, caused by a diplo- 
coccus (not of Neisser), 
144 
caused by various bacteria 
apart from the gonococ- 
cus, 147 
some other causes of nonspecific, 

in the male, 147 
treatment of gonorrheal, in wo- 
men, 175 ^/ seq. 



V. 

Vaginitis, gonorrheal, description 
of, 151 
treatment of, 203 
Venereal diseases, definition of, 17 
patients, alcohol for, 40, 178, 

195 
Vesicles, tuberculosis of the seminal, 

166 
Vesicular syphilides in hereditary 

syphilis, 126 
Vesiculitis, gonorrheal seminal, 164 
caused by the gonococ- 

cus, 164 
treatment of, 195 
sometimes cause of discharge, 165 
Virus, the syphilitic, 19, 22, 52 
Viscera, affections of the, in acquired 
syphilis, 93 
in hereditary syphilis, 131 
Vocal cords, syphilis of the, 88 
Voice, the, in syphilis hereditaria 

tarda, 135 
Vulvitis, gonorrheal, 150 
treatment of, 202 

W. 

Warts in gonorrhea, 172 

treatment of, 201 
Women, affections of the urethra in 
gonorrhea in, 151 
gonorrhea of. 150 
treatment of gonorrheal follicul- 
itis in, 201 
urethritis in, 201 



NO. 8 November, 1900 

A Classified Catalogue of 
Books on Medicine and the 
Collateral Sciences, Phar- 
macy, Dentistry, Chemistry, 
Hygiene, Microscopy, Etc. 



e^F 



P. Blakiston's Son & Company, Pub- 
lishers of Medical and Scientific Books, 
1012 Walnut Street, Philadelphia 



SUBJECT INDEX. 



Special Catalogues of Books on Pharmacy, Dentistry, 
Chemistry, Hygiene, and Nursing will be sent free upon 
application. All inquiries regarding prices, dates of edition, 
terms, etc., will receive prompt attention. 



SUBJECT PAGE 

Alimentary Canal (see Surgei y) 19 

Anatomy 3 

Anesthetics 14 

Autopsies (see Pathology) 16 

Bacteriology (see Pathology) . 16 

Bandaging (see Surgery) 19 

Blood, Examination of 16 

Brain 4 

Chemistry 4 

Children, Diseases of 6 

Climatology 14 

Clinical Charts 6 

Compends 22,23 : 

Consumption (see Lungs) 11 

Cyclopedia of Medicine 8 

Dentistry 7 

Diabetes (see Urin. Organs).. 21 

Diagnosis 17 | 

Diagrams (see Anatomy) 3 

Dictionaries, Cyclopedias 8 

Diet and Food 14 

Dissectors 3 

Ear 9 

Electricity 9 

Emergencies (see Surgery) 19 

Eye 9 

Fevers 9 

Gout .... 10 

Gynecology 21 

Hay Fever 20 

Heart 10 

Histology 10 

Hospitals (see Hygiene) 11 

Hydrotherapy 14 

Hygiene 11 

Insanity 4 

Intes-tines (see Miscellaneous) 14 
Latin, Medical (see Miscella- 
neous and Pharmacy) 14, 16 

Life Insurance 14 

Lungs 12 

Massage 12 

Materia Medica 12 

Medical Jurisprudence 13 

Microscopy 13 

Milk Analysis (see Chemistry) 4 



SUBJECT. PAGE 

Miscellaneous 14 

Nervous Diseases 14 

Nose 20 

Nursing 15 

Obstetrics 16 

Ophthalmology 9 

Organotherapy 14 

Osteology (see Anatomy) 3 

Pathology 16 

Pharmacy 16 

Physical Diagnosis 17 

Physical Training (see Miscel- 
laneous) 14 

Physiology 17 

Pneumotherapy 14 

Poisons (see Toxicology) 13 

Popular Medicine 10 

Practice of Medicine 18 

Prescription Books 18 

Refraction (see Eye) 9 

Rheumatism 10 

Sanitary Science 11 

Skin 19 

Spectacles (see Eye) 9 

Spine (see Nervous Diseases) 14 
Stomach (see Miscellaneous)... 14 

Students' Compends 22, 23 

Surgery and Surgical Dis- 
eases 19 

Syphilis 21 

Technological Books 4 

Temperature Charts 6 

Therapeutics 12 

Throat 20 

Toxicology 13 

Tumors (see Surgery) iq 

TJ. S. Pharmacopoeia 17 

Urinary Organs 20 

Urine 20 

Venereal Diseases 21 

Veterinary Medicine 21 

Visiting Lists, Physicians'. 
{Send for Special Circular.') 

Water Analysis 11 

Women, Diseases of. 21 



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vision of George M. Gould, m.d., Author of "An Illustrated 
Dictionary of Medicine " : Editor "Philadelphia Medical Journal," 
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TREVES AND LANG. German-English Medical Dictionary . 

Half Russia, $3.25 



MEDICAL BOOKS. 



EAR (see also Throat and Nose). 

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ELECTRICITY. 

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HEDLEY. Therapeutic Electricity and Practical Muscle 
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DONDERS. The Nature and Consequences of Anomalies of 
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FICK. Diseases of the Eye and Ophthalmoscopy. Trans- 
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GOULD AND PYLE. Compend of Diseases of the Eye and 
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Cloth, .80 ; Interleaved, gi.co 

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JESSOP. Manual of Ophthalmic Surgery and Medicine. Col- 
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10 SUBJECT CATALOGUE. 

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rection of its Errors. 6th Edition. $1.00 

OHLEMANN. Ocular Therapeutics. Authorized Translation, 
and Edited by Dr. Charles A. Oliver. $i 75 

PHILLIPS. Spectacles and Eyeglasses. Their Prescription 
and Adjustment. 2d Edition. 49 Illustrations. $1.00 

SWANZY. Diseases of the Eye and Their Treatment. 7 th 

Edition, Revised and Enlarged. 164 Illustrations, 1 Plain Plate, 
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THORINGTON. Retinoscopy. 3d Edition. Illustrated. $1.00 

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GOODALL AND WASHBOURN. Fevers and Their Treat- 
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DUCKWORTH. A Treatise on Gout. With Chromo-lithographs 
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HAIG. Causation of Disease by Uric Acid. A Contribution to 
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HEART. 

SANSOM. Diseases of the Heart. The Diagnosis and Pathology 
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Illustrations. $6.00 

THORNE. The Schott Methods of the Treatment of Chronic 
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STIRLING. Outlines of Practical Histology. 368 Illustrations. 
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STOHR. Histology and Microscopical Anatomy. Translated 
and Edited by A. Schaper, m.d., Harvard Medical School. Second 
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MEDICAL BOOKS. 



HYGIENE AND WATER ANALYSIS. 

Special Catalogue of Books on Hygiene sent free upon application. 

CANFIELD. Hygiene of the Sick-Room. A Book for Nurses 
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COPLIN. Practical Hygiene. A Complete American Text-Book. 
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LEFFMANN. Analysis of Milk and Milk Products. Illus- 
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LINCOLN. School and Industrial Hygiene. .40 

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NOTTER. The Theory and Practice of Hygiene. 15 Plates 
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PARKES. Popular Hygiene. The Elements of Health. A Book 
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Management of the Ordinary Emergencies of Early Life, Massage, 
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STEVENSON AND MURPHY. A Treatise on Hygiene. By 
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THRESH. Water and Water Supplies. 2d Edition. $2.00 

WILSON. Hand-Book of Hygiene and Sanitary Science. 

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WEYL. Sanitary Relations of the Coal-Tar Colors. Author- 
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HARRIS AND BEALE. Treatment of Pulmonary Consump- 
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KNOPF. Pulmonary Tuberculosis. Its Mjdern Prophylaxis 
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POWELL. Diseases of the Lungs and Pleurae, including 
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12 SUBJECT CATALOGUE. 

MASSAGE. 

KLEEN. Hand-Book of Massage. Authorized translation by 
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Weir Mitchell. Illustrated by a series of Photographs Made 
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MITCHELL AND GULICK. Mechanotherapy. Illus. In Press. 

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MATERIA MEDICA AND THERA- 
PEUTICS. 

BIDDLE. Materia Medica and Therapeutics. Including Dose 
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BRACKEN. Outlines of Materia Medica and Pharmacology. $2.75 

COBLENTZ. The Newer Remedies. Including their Synonyms, 
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COHEN. Physiologic Therapeutics. Mechanotherapy, Mental 
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DAVIS. Materia Medica and Prescription Writing. $1 50 

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HELLER. Essentials of Materia Medica, Pharmacy, and 
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MAYS. Theine in the Treatment of Neuralgia. J£ bound, .50 

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POTTER. Compend of Materia Medica, Therapeutics, and 
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MEDICAL BOOKS. 13 



SAYRE. Organic Materia Medica and Pharmacognosy. An 

Introduction to the Study of the Vegetable Kingdom and the Vege- 
table and Animal Drugs. Comprising the Botanical and Physical 
Characteristics. Source, Constituents, and Pharmacopeial Prepara- 
tions, Insects Injurious to Drugs, and Pharmacal Botany. With 
sections on Histology and Microtechnique, by W. C. Stevens. 
374 Illustrations, many of which are original. 2d Edition. 

Cloth, $4.50 

WHITE AND WILCOX. Materia Medica, Pharmacy, Phar- 
macology, and Therapeutics. 4th American Edition, Revised by 
Reynold W. Wilcox, m.a.. m d., ll.d.. Professor of Clinical 
Medicine and Therapeutics at the New York Post-Graduate Medical 
School. Cloih,$3oo; Leather, $3.50 

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the best book on Materia Medica and Therapeutics to place in the 
hands of students, and the practitioner will find it a most satisfactory 
work for daily use." — The Cleveland Medical Gazette. 



MEDICAL JURISPRUDENCE AND 
TOXICOLOGY. 

REESE. Medical Jurisprudence and Toxicology. A Text-Book 
for Medical and Legal Practitioners and Students. 5th Edition. 
Revised by Henry Leffmann, m.d. Clo., $3.00 ; Leather, $3.50 

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American Journal of the Medical Sciences. 

MANN. Forensic Medicine and Toxicology. Illus. $6.50 

TANNER. Memoranda of Poisons. Their Antidotes and Tests. 
7th Edition. .75 



MICROSCOPY. 

CARPENTER. The Microscope and Its Revelations. 8th 

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LEE. The Microtomist's Vade Mecum. A Hand-Book of 
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REEVES. Medical Microscopy, including Chapters on Bacteri- 
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WETHERED. Medical Microscopy. A Guide to the Use of the 
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SUBJECT CATALOGUE. 



MISCELLANEOUS. 

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DAVIS. Alimentotherapy. In Press. 

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GREENE. Medical Examination for Life Insurance. Illus- 
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GOWERS. Syphilis and the Nervous System. $1.00 



MEDICAL BOOKS. 15 



GOWERS. Clinical Lectures. A New Volume of Essays on the 
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GOWERS. Epilepsy and Other Chronic Convulsive Diseases. 
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NURSING (see also Massage). 

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BROWN. Elementary Physiology for Nurses. .75 

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CUFF. Lectures to Nurses on Medicine. New Edition, gi.25 

DOMVILLE. Manual for Nurses and Others Engaged in At- 
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Edition. 25 Illustrations. $1.00 

TEMPERATURE AND CLINICAL CHARTS. See page 6. 

VOSWINKEL. Surgical Nursing. Second Edition, Enlarged. 

112 Illustrations. $1.00 

WESTLAND. The Wife and Mother. $1.50 



16 SUBJECT CATALOGUE 

OBSTETRICS. 

CAZEAUX AND TARNIER. Midwifery. With Appendix by 
Mund6. The Theory and Practice of Obstetrics, including the Dis- 
eases ot Pregnancy and Parturition, Obstetrical Operations, etc. 
8th Edition. Illustrated by Chromo-Lithographs, Lithographs, and 
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numerous Wood Engravings. Cloth, $4.50 ; Full Leather, $5.50 

DAVIS. A Manual of Obstetrics. 3d Edition. Preparing. 

EDGAR. Text-Book of Obstetrics. Illustrated. Preparing. 

LANDIS. Compend of Obstetrics. 6th Edition, Revised by Wm. 
H. Wells, Assistant Demonstrator oi Clinical Obstetrics, Jefferson 
Medical College. With 47 Illustrations, .80; Interleaved, Ji.co 

WINCKEL. Text-Book of Obstetrics, Including the Pathol- 
ogy and Therapeutics of the Puerperal State. Authorized 
Translation by J. Clifton Edgar, a.m., m.d. With nearly 200 Illus- 
trations. Cloth, $5.00; Leather, $6.00 

FULLERTON. Obstetric Nursing. 5th Ed. Illustrated. $1.00 

PATHOLOGY. 

BARLOW. General Pathology. 795 pages. 8vo. $5.00 

BLACK. Micro-Organisms. The Formation of Poisons. .75 

BLACKBURN. Autopsies. A Manual of Autopsies Designed foi 
the Use ot Hospitals for the Insane and other Public Institutions. 
Ten full-page Plates and other Illustrations. $i-25 

COMPEND of General Pathology. Illustrated. Preparing. 

COPLIN. Manual of Pathology. Including Bacteriology, Technic 
of Post-Mortems, Methods of Pathologic Research, etc. 330 Illus- 
trations, 7 Colored Plates, many of which are original. 3d Edition. 
Just Ready. $3-5© 

DA COSTA. Clinical Pathology of the Blood. Illus. InPress. 
GILLIAM. Pathology. A Hand-Book for Students. 47 Illus. .75 
HEWLETT. Manual of Bacteriology. 75 Illustrations. $3.00 
VIRCHOW. Post-Mortem Examinations. A Description and 
Explanation of the Method of Performing Them in the Dead House 
of the Berlin Charity Hospital, with Special Reference to Medico- 
Legal Practice. 3d Edition, with Additions. .75 
WHITACRE. Laboratory Text-Book of Pathology. With 
121 Illustrations. $ I -5° 
WILLIAMS. Bacteriology. A Manual for Students. 78 Illus- 
trations. $i-5° 

PHARMACY. 

Special Catalogue of Books on Pharmacy sent free upon application. 

COBLENTZ. Manual of Pharmacy. A Complete Text-Book 
by the Professor in the New York College of Pharmacy. ?& Edition. 
Revised and Enlarged. 437 Illus. Cloth, 83.50; Sheep, $4 50 

BEASLEY. Book of 3100 Prescriptions. Collected from th» 
Practice of the Most Eminent Physicians and Surgeons — English 
French, and American. A Compendious History ot the Materia 
Medica, Lists of the Doses of all the Officinal and Established Pre- 
parations, an Irdexof Diseases and their Remedies. 7th Ed. $2.00 



MEDICAL BOOKS. 17 



BEASLEY. Druggists' General Receipt Book. Comprising 
a Copious Veterinary Formulary, Recipes in Patent and Proprietary 
Medicines, Druggists' Nostrums, etc. ; Perfumery and Cosmetics, 
Beverages, Dietetic Articles and Condiments, Trade Chemicals, 
Scientific Processes, and many Useful Tables, ioth Ed. $2.00 

BEASLEY. Pharmaceutical Formulary. A Synopsis of the 
British, French, German, and United States Pharmacopoeias. Com- 
prising Standard and Approved Formulae for the Preparations and 
Compounds Employed in Medicine. 12th Edition. $2.00 

PROCTOR. Practical Pharmacy. Lectures on Practical Phar- 
macy. With Wood Engravings and 32 Lithographic Fac-simile 
Prescriptions. 3d Edition, Revised, and with Elaborate Tables of 
Chemical Solubilities, etc. $3.00 

ROBINSON. Latin Grammar of Pharmacy and Medicine. 
3d Edition. With elaborate Vocabularies. $!-75 

SAYRE. Organic Materia Medica and Pharmacognosy. An 
Introduction to the Study of the Vegetable Kingdom and the Vege- 
table and Animal Drugs. Comprising the Botanical and Physical 
Characteristics, Source, Constituents, and Pharmacopeial Prepar- 
ations, Insects Injurious to Drugs, and Parmacal Botany. With 
sections on Histology and Microtechnique, by W. C. Stevens. 
374 Illustrations. Second Edition. Cloth, $4.50 

SCOVILLE. The Art of Compounding. Second Edition, Re- 
vised and Enlarged. Cloth, $2.50 

STEWART. Compend of Pharmacy. Based upon " Reming- 
ton's Text-Book of Pharmacy." 5th Edition, Revised in Accord- 
ance with the U. S. Pharmacopoeia, 1890. Complete Tables of 
Metric and English Weights and Measures. .80; Interleaved, $1.00 

UNITED STATES PHARMACOPOEIA. 7th Decennial Revision. 
Cloth, $2.50 (postpaid, $2.77) ; Sheep, $3.00 (postpaid, $3.27) ; Inter- 
leaved, $4.00 (postpaid. $4.50); Printed on one side of page only, 
unbound, $3.50 (postpaid, £3.90). 

Select Tables from the U. S. P. Being Nine of the Most Impor- 
tant and Useful Tables, Printed on Separate Sheets. Carefully 
put up in patent envelope. .25 

POTTER. Hand-Book of Materia Medica, Pharmacy, and 
Therapeutics. 600 Prescriptions. 7th Ed. Clo., $5.00 ; Sh., $6.00 

PHYSICAL DIAGNOSIS. 

BROWN. Medical Diagnosis. A Manual of Clinical Methods. 
4th Edition. 112 Illustrations. Cloth, $2.25 

DA COSTA. Clinical Examination of the Blood. Illustrated. 

In Press. 

FENWICK. Medical Diagnosis. 8th Edition. Rewritten and 
very much Enlarged. 135 Illustrations. Cloth, $2.50 

MEMMINGER. Diagnosis by the Urine. 2d Ed. 24 Illus. $100 

TYSON. Hand-Book of Physical Diagnosis. For Students and 
Physicians. By the Professor of Clinical Medicine in the University 
of Pennsylvania. Illus. 3d Ed., Improved and Enlarged. With 
Colored and other Illustrations. $i-5<> 

PHYSIOLOGY. 

BIRCH. Practical Physiology. An Elementary Class Book. 

62 Illustrations. $t-75 

BRUBAKER. Compend of Physiology, ioth Edition, Revised 

and Enlarged. Illustrated. Just Ready. .80; Interleaved, $1.00 

2 



18 SUBJECT CATALOGUE. 

KIRKES. Physiology. (16th Authorized Edition. Dark-Red Cloth.) 
A Hand-Book of Physiology. 16th Edition, Revised, Rearranged, 
and Enlarged. By Prof. W. D. Halliburton, of Kings College, 
London. 671 Illustrations, some of which are printed in colors. 
Just Ready. Cloth, $3.00; Leather, $3.75 

LANDOIS. A Text-Book of Human Physiology, Including 
Histology and Microscopical Anatomy, with Special Reference to 
the Requirements of Practical Medicine. 5th American, translated 
from the 9th German Edition, with Additions by Wm. Stirling, 
m.d.,d.sc. 845 Illus., many of which are printed in colors. In Press. 

STARLING. Elements of Human Physiology. 100 Ills. $1.00 

STIRLING. Outlines of Practical Physiology. Including 
Chemical and Experimental Physiology, with Special Reference to 
Practical Medicine. 3d Edition. 289 Illustrations. #2.00 

TYSON. Cell Doctrine. Its History and Present State. $1.50 

PRACTICE. 

BEALE. On Slight Ailments; their Nature and Treatment. 

2d Edition, Enlarged and Illustrated. $ l -25 

FOWLER. Dictionary of Practical Medicine. By various 
writers. An Encyclopaedia of Medicine. Clo.,$3.oo; Half Mor. $4.00 
GOULD AND PYLE. Cyclopedia of Practical Medicine and 
Surgery. A Concise Reference Handbook, Alphabetically 
Arranged, with particular Reference to Diagnosis and Treatment. 
Edited by Drs. Gould and Pyle, Assisted by 72 Special Con- 
tributors. Illustrated, one volume. Large Square Octavo, Uniform 
with " Gould's Illustrated Dictionary." Just Ready. 

Sheep or Half Morocco, $'0.00: with Thumb Index, $11.00 
Half Russia, Thumb Index, $12 00 
4®^ Complete descriptive circular with sample pages and illustra- 
tions of this book zvill be sent free upon application. 
HUGHES. Compend of the Practice of Medicine. 6th Edition, 
Revised and Enlarged. Just Ready. 

Part I. Continued, Eruptive, and Periodical Fevers, Diseases of the 
Stomach, Intestines, Peritoneum, Biliary Passages, Liver, Kid- 
neys, etc., and General Diseases, etc. 
Part II. Diseases of the Respiratory System, Circulatory System, 
and Nervous System; Diseases of the Blood, etc. 

Price of each part, .80; Interleaved, $1.00 
Physician's Edition. In one volume, including the above two 
parts, a Section on Skin Diseases, and an Index. 6th Revised 
Edition. 625 pp. Just Ready. Full Morocco, Gilt Edge, $2.25 
TAYLOR. Practice of Medicine. 5th Kdition. Cloth, $4.00 

TYSON. The Practice of Medicine. By James Tyson, m.d., 
Professor of Medicine in the University of Pennsylvania. A Com- 
plete Systematic Text-book with Special Reference to Diagnosis and 
Treatment. 2d Edition, Enlarged and Revised. Colored Plates and 
125 other Illustrations. 1222 Pages. 8vo. Just Ready. 

Cloth, $5.50; Leather, $6.50 

PRESCRIPTION BOOKS. 

BEASLEY. Book of 3100 Prescriptions. Collected from the 
Practice of the Most Eminent Physicians and Surgeons — English, 
French, and American. A Compendious History of the Materia, 
Medica, Lists of the Doses of all Officinal and Established Prepara- 
tions, and an Index of Diseases and their Remedies. 7th Ed. $2.00 



MEDICAL BOOKS. 19 



BEASLEY. Druggists' General Receipt Book. Comprising 
a Copious Veterinary Formulary, Recipes in Patent and Proprie- 
tary Medicines, Druggists' Nostrums, etc. ; Perfumery and Cos- 
metics, Beverages, Dietetic Articles and Condiments, Trade Chem- 
icals, Scientific Processes, and an Appendix of Useful Tables, 
roth Edition, Revised. $2.00 

BEASLEY. Pocket Formulary. A Synopsis of the British, French, 
German, and United States Pharmacopoeias and the chief unofficial 
Formularies. 12th Edition. $2.00 

SKIN. 

BULKLEY. The Skin in Health and Disease. Illustrated. .40 
CROCKER. Diseases of the Skin. Their Description, Pathol- 
ogy, Diagnosis, and Treatment, with Special Reference to the Skin 
Eruptions of Children. 92 Illus. 3d Edition. Preparing. 

IMPEY. Leprosy. 37 Plates. 8vo. £3.50 

SCHAMBERG. Diseases of the Skin. 2d Edition, Revised and 
Enlarged. 105 Illustrations. Being No. 16 ? Quiz-Compend? Series. 
Just Ready. Cloth, .80; Interleaved, $1.00 

VAN HARLINGEN. On Skin Diseases. A Practical Manual 
of Diagnosis and Treatment, with special reference to Differential 
Diagnosis. 3d Edition, Revised and Enlarged. With Formulae 
and 60 Illustrations, some of which are printed in colors. $2.75 

SURGERY AND SURGICAL DIS- 
EASES (see also Urinary Organs). 

BUTLIN. Operative Surgery of Malignant Disease. 2d Edi- 
tion. Illustrated. Octavo. Just Ready. $4. 50 
CRIPPS. Ovariotomy and Abdominal Surgery. Illus. $8.00 
DEAVER. Surgical Anatomy. A Treatise on Human Anatomy 
in its Application to Medicine and Surgery. With about 400 very 
Handsome full-page Illustrations Engraved from Original Drawings 
made by special Artists from Dissections prepared for the purpose. 
Three Volumes. Royal Square Octavo. 

Cloth, $21. 00; Half Morocco or Sheep, $24.00 ; Half Russia, $27.00 
Complete descriptive circular and special terms upon application. 

DEAVER. Appendicitis, Its Symptoms, Diagnosis, Pathol- 
ogy. Treatment, and Complications. Elaborately Illustrated 
with Colored Plates and other Illustrations. 2d Edition. $3. 50 

DULLES. What to Do First in Accidents and Poisoning. 
5th Edition. New Illustrations. $1.00 

FULLERTON. Surgical Nursing. 3d Edition. 69 Illus. $x 00 

HAMILTON. Lectures on Tumors, from a Clinical Stand- 
point. Third Edition, Revised, with New Illustrations. $ 1 -^5 

HEATH. Minor Surgery and Bandaging, nth Ed., Revised 
and Enlarged. 176 Illustrations, Formulae, Diet List, etc. $1.25 

HEATH. Injuries and Diseases of the Jaws. 4th Edition. 
187 Illustrations. $4-50 

HEATH. Lectures on Certain Diseases of the Jaws. 64 Illus- 
trations. Boards, .50 



20 SUBJECT CATALOGUE. 

HORWITZ. Compend of Surgery and Bandaging, including 
Minor Surgery, Amputations, Fractures, Dislocations, Surgical Dis- 
eases, and the Latest Antiseptic Rules, etc., with Differential Diagno- 
sis and Treatment. 5th Edition, very much Enlarged and Rear- 
ranged. 167 Illustrations, 98 Formulae. Clo., .80 ; Interleaved, $1.25 

JACOBSON. Operations of Surgery. Over 200 Illustrations. 

Cloth, $3.00 ; Leather, $4.00 
JACOBSON. Diseases of the Male Organs of Generation. 

88 Illustrations. |6.oo 

LANE. Surgery of the Head and Neck, no Illustrations. 
2d Edition. $5.00 

MACREADY. A Treatise on Ruptures. 24 Full-page Litho- 
graphed Plates and Numerous Wood Engravings. Cloth, $6.00 
MAYLARD. Surgery of the Alimentary Canal. 97 Illustrations. 
2d Edition, Revised. Just Ready. $3.00 

MOULLIN. Text-Book of Surgery. With Special Reference to 
Treatment. 3d American Edition. Revised and edited by John B. 
Hamilton, m.d., ll.d., Professor of the Principles of Surgery and 
Clinical Surgery, Rush Medical College, Chicago. 623 Illustrations, 
Over 200 of which are original, and many of which are printed in 
colors. Handsome Cloth, $6.00; Leather, $7.00 

ROBERTS. Fractures of the Radius. A Clinical and Patho- 
logical Study. 33 Illustrations. $1.00 

SMITH. Abdominal Surgery. Being a Systematic Description of 
all the Principal Operations. 224 Illus. 6th Ed. 2 Vols. Clo., $10.00 

SWAIN. Surgical Emergencies. Fifth Edition. Cloth, $1.75 

VOSWINKEL. Surgical Nursing. Second Edition, Revised and 
Enlarged, in Illustrations. $1.00 

WALSHAM. Manual of Practical Surgery. 7 th Ed., Re- 
vised and Enlarged. 483 Engravings. 950 pages. Just Ready. $3.50 

THROAT AND NOSE (see also Ear). 
COHEN. The Throat and Voice. Illustrated. .40 

HALL. Diseases of the Nose and Throat. Two Colored 

Plates and 59 Illustrations. New Edition Preparing. 

HOLLOPETER. Hay Fever. Its Successful Treatment. $1.00 

KNIGHT. Diseases of the Throat. A Manual for Students. 
Illustrated. Nearly Ready. 

MACKENZIE. Pharmacopoeia of the London Hospital for 
Dis. of the Throat. 5th Ed., Revised by Dr. F. G. Harvey $1.00 

McBRIDE. Diseases of the Throat, Nose, and Ear. With col- 
ored Illus. from original drawings. 3d Ed. Just Ready $7.00 

POTTER. Speech and its Defects. Considered Physiologically, 
Pathologically, and Remedially. $1.00 



URINE AND URINARY ORGANS. 

ACTON. The Functions and Disorders of the Reproductive 
Organs in Childhood, Youth, Adult Age, and Advanced Life, 
Considered in their Physiological, Social, and Moral Relations. 
8th Edition. $1.75 



MEDICAL BOOKS. 21 



BEALE, One Hundred Urinary Deposits. On eight sheets, 
for the Hospital, Laboratory, or Surgery. Paper, $2.00 

HOLLAND. The Urine, the Gastric Contents, the Common 
Poisons, and the Milk. Memoranda, Chemical and Microscopi- 
cal, for Laboratory Use. Illustrated and Interleaved. 6th Ed. $1.00 

JACOBSON. Male Organs of Generation. 88 Illus. $6.00 

KEHR. Gall-Stone Disease. Translated by William Watkyns 
Seymouk, m d. In Press. 

KLEEN. Diabetes and Glycosuria. #2.50 

MEMMINGER. Diagnosis by the Urine. 2d Ed. 24 Illus. $1.00 

MORRIS. Renal Surgery, with Special Reference to Stone in the 
Kidney and Ureter and to the Surgical Treatment of Calculous 
Anuria. Illustrated. #2.00. 

MOULLIN. Enlargement of the Prostate. Its Treatment and 
Radical Cure. 2d Edition. Illustrated. Just Ready. $*-75 

MOULLIN. Inflammation of the Bladder and Urinary Fever. 
Octavo. $1.50 

SCOTT. The Urine. Its Clinical and Microscopical Examination. 
41 Lithographic Plates and other Illustrations. Quarto. Cloth, $5.00 

TYSON. Guide to Examination of the Urine. For the Use of 
Physicians and Students. With Colored Plate and Numerous Illus- 
trations engraved on wood. 9th Edition, Revised. $1-25 

VAN NUYS. Chemical Analysis of Urine. 39 Illus. $1.00 

VENEREAL DISEASES. 

COOPER. Syphilis. 2d Edition, Enlarged and Illustrated with 

20 full-page Plates. $5.00 

GOWERS. Syphilis and the Nervous System. 1.00 

STURGIS. Student's Manual of Venereal Diseases. 7th 

Revised and Enlarged Edition. i2mo. In Press. 

VETERINARY. 

BALLOU. Veterinary Anatomy and Physiology. 29 Graphic 
Illustrations. .80; Interleaved, $1. 00 

TUSON. Veterinary Pharmacopoeia. Including the Outlines of 
Materia Medica and Therapeutics. 5th Edition. $2.25 

WOMEN, DISEASES OF. 

BYFORD (H. T.). Manual of Gynecology. Second Edition, 
Revised and Enlarged by 100 pages. 341 Illustrations. $300 

DUHRSSEN. A Manual of Gynecological Practice. 105 
Illustrations. $r.5o 

FULLERTON. Surgical Nursing. 3d Edition, Revised and 
Enlarged. 69 Illustrations. $1.00 

LEWERS. Diseases of Women. 146 Illus. 5th Ed. $2.50 

MONTGOMERY. Practical Gynecology. A Complete Sys- 
tematic Text-Book. 527 Handsome Illustrations. 8vo. Just Ready. 

Cloth, $5.00 ; Leather, $6.00 

WELLS. Compend of Gynecology. Illustrated. 2d Edition. 

.80; Interleaved, $1. 00 



22 SUBJECT CATALOGUE. 

COMPENDS. 



From The Southern. Clinic. 

" We know of no series of books issued by any house that so fully 
meets our approval as these ?Quiz-Compends?. They are well ar- 
ranged, full, and concise, and are really the best line of text-books that 
could be found for either student or practitioner." 



BLAKISTON'S ?QUIZ-COMPENDS? 

The Best Series of Manuals for the Use of Students. 
Price of each, Cloth, .80. Interleaved, for taking Notes, $1.00. 

£5"- These Compends are based on the most popular text-books 
and the lectures of prominent professors, and are kept constantly re- 
vised, so that they may thoroughly represent the present state of the 
subjects upon which they treat. 

43f" The authors have had large experience as Quiz-Masters and 
attaches of colleges, and are well acquainted with the wants of students. 

J%g- They are arranged in the most approved form, thorough and 
concise, containing over 600 fine illustrations, inserted wherever they 
could be used to advantage. 

&$* Can be used by students of any college. 

4®* They contain information nowhere else collected in such a 
condensed, practical shape. Illustrated Circular free. 

No. 1. POTTER. HUMAN ANATOMY. Sixth Revised and 

Enlarged Edition. Including Visceral Anatomy. Can be used 
with either Morris's or Gray's Anatomy. 117 Illustrations and 16 
Lithographic Plates of Nerves and Arteries, with Explanatory 
Tables, etc. By Samuel O. L. Potter, m.d., Professor of the 
Practice of Medicine, College of Physicians and Surgeons, San 
Francisco ; Br'gade Surgeon, U. S. Vol. 

No. 2. HUGHES. PRACTICE OF MEDICINE. Part I. Sixth 
Edition, Enlarged and Improved. By Daniel E. Hughes,m.d., 
Physician-in-Chief, Philadelphia Hospital, late Demonstrator of 
Clinical Medicine, Jefferson Medical College, Phila. 

No. 3. HUGHES. PRACTICE OF MEDICINE. Part II. 
Sixth Edition, Revised and Improved. Same author as No. 2. 

No. 4. BRUBAKER. PHYSIOLOGY. Tenth Edition, with 
Illustrations and a table of Physiological Constants. Enlarged 
and Revised. By A. P. Brubaker, m.d., Professor of Physiology 
and General Pathology in the Pennsylvania College of Dental 
Surgery; Adjunct Professor of Physiology, Jefferson Medical 
College, Philadelphia, etc. 

No. 5. LANDIS. OBSTETRICS. Sixth Edition. By Henry G. 
Landis, m.d. Revised and Edited by Wm. H. Wells, m.d., 
Instructor of Obstetrics, Jefferson Medical College, Philadelphia. 
Enlarged. 47 Illustrations. 

No. 6. POTTER. MATERIA MEDICA, THERAPEUTICS, 
AND PRESCRIPTION WRITING. Sixth Revised Edition 
(U. S. P. 1890). By Samuel O. L. Potter, m.d., Professor of 
Practice, College of Physicians and Surgeons, San Francisco; 
Brigade Surgeon, U. S. Vol. 



MEDICAL BOOKS. 23 



PQUIZ-COMPENDS ?— Continued. 

No. 7. WELLS. GYNECOLOGY. Second Edition. By Wm. H. 
Wells, m.d., Instructor of Obstetrics, Jefferson College, Philadel- 
phia. 140 Illustrations. 

No. 8. GOULD AND PYLE. DISEASES OF THE EYE 
AND REFRACTION. Second Edition. Including Treatment 
and Surgery, and a Section on Local Therapeutics. By George 
M. Gould, m.d., and W. L. Pyle, m.d. With Formulae, Glossary, 
Tables, and 109 Illustrations, several of which are Colored. 

No. 9. HORWITZ. SURGERY, Minor Surgery, and Bandag- 
ing. Fifth Edition, Enlarged and Improved. By Orville 
Horwitz, b. s-, m.d., Clinical Professor of Genito-Urinary Surgery 
and Venereal Diseases in Jefferson Medical College ; Surgeon to 
Philadelphia Hospital, etc. With 98 Formulae and 71 Illustrations. 

No. 10. LEFFMANN. MEDICAL CHEMISTRY. Fourth 

Edition. Including Urinalysis, Animal Chemistry, Chemistry of 
Milk, Blood, Tissues, the Secretions, etc. By Henry Leffmann, 
m.d., Professor of Chemistry in Pennsylvania College of Dental 
Surgery and in the Woman's Medical College, Philadelphia. 

No. 11. STEWART. PHARMACY. Fifth Edition. Based upon 
Prof. Remington's Text-Book of Pharmacy. By F. E. Stewart, 
m.d., ph.g., late Quiz-Master in Pharmacy and Chemistry, Phila- 
delphia College of Pharmacy ; Lecturer at Jefferson Medical 
College. Carefully revised in accordance with the new U. S. P. 

No. 12. BALLOU. VETERINARY ANATOMY AND PHY- 
SIOLOGY. Illustrated. By Wm. R. Ballou, m.d., Professor 
of Equine Anatomy at New York College of Veterinary Surgeons ; 
Physician to Bellevue Dispensary, etc. 29 graphic Illustrations 

No. 13. WARREN. DENTAL PATHOLOGY AND DEN- 
TAL MEDICINE. Third Edition, Illustrated. Containing 
a Section on Emergencies. By Geo. W. Warren, d.d.s., Chief 
of Clinical Staff, Pennsylvania College of Dental Surgery. 

No. 14. HATFIELD. DISEASES OF CHILDREN. Second 
Edition. Colored Plate. By Marcus P. Hatfield, Profes- 
sor of Diseases of Children, Chicago Medical College. 

No. 15. GENERAL PATHOLOGY. Illustrated Preparing. 

No. 16. DISEASES OF THE SKIN. Second Edition. By 
Jay F. Schamberg, m.d., Professor of Diseases of the Skin, 
Philadelphia Polyclinic. Second Edition, Revised and Enlarged. 
105 handsome Illustrations. 

Price, each, Cloth, .80. Interleaved, for taking Notes, $1.00 

In preparing, revising, and improving Blakiston's ? Quiz-Com- 
pends ? the particular wants of the student have always been kept in 
mind. 

Careful attention has been given to the construction of each sentence, 
and while the books will be found to contain an immense amount of 
knowledge in small space, they will likewise be found easy reading ; 
there is no stilted repetition of words ; the style is clear, lucid, and dis- 
tinct. The arrangement of subjects is systematic and thorough ; there 
Is a reason for every word. They contain over 600 illustrations. 



Morris' 
Anatomy 

Second Edition, Revised and Enlarged. 

790 Illustrations, of which many 
are in Colors. 

Royal Octavo. Cloth, $6.00 ; Sheep, $7.00 ; 
Half Russia, $8.00. 



From The Medical Record, New York. 

" The reproach that the English language can boast of no 
treatise on anatomy deserving to be ranked with the masterly 
works of Henle, Luschka, Hyrtl, and others, is fast losing 
its force. During the past few years several works of great 
merit have appeared, and among these Morris's "Anatomy " 
seems destined to take first place in disputing the palm in 
anatomical fields with the German classics. The nomencla- 
ture, arrangement, and entire general character resemble 
strongly those of the above-mentioned handbooks, while in 
the beauty and profuseness of its illustrations it surpasses 
them. . . . The ever-growing popularity of the book 
with teachers and students is an index of its value, and it 
may safely be recommended to all interested." 

From The Philadelphia Medical Journal. 

" Of all the text-books of moderate size on human anatomy 
in the English language, Morris is undoubtedly the most 
up-to-date and accurate." 



*** Handsome Descriptive Circular, with Sample Pages and 
Colored Illustrations, will be sent free upon application. 



Jan - 12 %qq 1 



JAN 4 1901 



